Obsessive-Compulsive Disorder (OCD) is an obsessive-compulsive and related disorder that consists of (1) obsessions (intrusive, unwanted, and repetitive thoughts, urges, or images that don’t go away and are generally unwanted, or ego-dystonic) and/or (2) compulsions (repetitive physical behaviours or mental acts performed, meant to reduce the anxiety caused by the obsessions). Typical themes include contamination or cleaning, checking, symmetry, ordering or counting, as well as fears of harm to self or others. Obsessions can also be violent, sexual, or religious in nature.
Presence of obsessions, compulsions, or both:
Obsessions are defined by (1) and (2):
Compulsions are defined by (1) and (2):
The obsessions or compulsions are time-consuming (e.g. - take more than 1
hour per
day) or cause clinically significant distress or impairment in social, occupational, or
other important areas of functioning.
The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
The disturbance is not better explained by the symptoms of another mental disorder:
MURDER
” can be used to remember the criteria for obssessive-compulsive disorder.[14]
M
- Mind (patient aware symptoms arise in the mind)U
- Unpleasant thoughtsR
- Resist (patient must want and try to resist the obsessive thoughts)D
- Displeasure of feeling the obsessionE
- Ego-dystonicR
- Repetitive thoughtsMost individuals with OCD will have both obsessions and compulsions. High sensitivity screening questions and a good OCD history includes the following:
Obsessions can be external or internal:
Descriptions/Examples | |
---|---|
Contamination | Concerns about dirt, germs, body waste, illness |
Symmetry | Needing things “just so”, even, or lined up a certain arbitrary way |
Aggressive | Most commonly focused on inadvertent harm, such as being responsible for a fire or break-in; also includes horrific thoughts or images of deliberately harming others, such as stabbing a loved one or pushing a stranger in front of a car |
Sexual | Disturbing sexual thoughts that are not consistent with an individual’s orientation or cultural norms, such as someone with a same-sex preference having unpleasant hetero-erotic thoughts, or unwanted inappropriate sexual thoughts about children |
Religious | Examples include thoughts about selling one’s soul to the devil, deliberately thinking inappropriate thoughts about major religious figures, or committing mortal sins |
Somatic | Exaggerated fears of contracting a serious illness such as hepatitis, or a brain tumour in the absence of any identifiable high risk |
Compulsions can be physical (behavioural) or mental (cognitive):
Descriptions/Examples | |
---|---|
Washing | Excessive hand-washing, showering, or cleaning activities |
Checking | Repeatedly turning the stove on and off; re-reading all emails to ensure content is appropriate; driving around the block to ensure didn’t hit someone; asking for repeated reassurance |
Ordering | Folding clothes “just so”, or arranging all cans in the cupboard so the labels are facing out |
Counting | Performing actions a certain arbitrary number of times, such as tapping each foot 4 times when getting out of bed |
Repeating | Repeatedly going up and down the stairs or flushing the toilet; typically done to “cancel” out a bad thought or until it feels “right” |
Name | Rater | Description | Download |
---|---|---|---|
Yale–Brown Obsessive Compulsive Scale (Y-BOCS) | Clinician/Self-report | A checklist and 10-item scale with severity rankings. It is the most widely used rating scale for OCD. Symptoms rated from 0 (none) to 4 (severe) in terms of: time spent, distress, resistance, control, and interference with functioning | |
Florida Obsessive Compulsive Inventory (FOCI) | Patient | A self-rated measure also used in monitoring OCD symptoms |
Functional neuroimaging from PET, fMRI, and SPECT have shown that several brain structures are implicated in OCD:
The differential diagnosis for OCD includes anxiety disorders, depression, complex tics, eating disorders, and psychosis. OCD is considered to be on a spectrum that encompasses comorbid conditions like hoarding disorder, excoriation disorder, trichotillomania disorder and body dysmorphic disorder. All these conditions are generally characterized by specific types of preoccupations and/or repetitive behaviours. It is important that the clinician be aware of all of these related conditions, as they must be differentiated from one another. See also Criterion D of the DSM-5 diagnostic criterion.
A specialized form of CBT, called Exposure and Response/Ritual Prevention Therapy (ERP) is the gold standard and first-line treatment for OCD, and favoured over medications.
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Distressing Situation/Item | Distress (Scale 0 to 100) |
---|---|
Most distressing: touching public washroom door handle | 100 |
2nd most distressing: pumping gas | 70 |
3rd most distressing: gardening with gloves; turning stove on/off | 50 |
4th most distressing: washing off cans, bottles, bags | 40 |
1st line | Monotherapy: escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline |
---|---|
2nd line | Monotherapy: citalopram, clomipramine, mirtazapine, venlafaxine XR |
3rd line | Monotherapy: IV citalopram, IV clomipramine, duloxetine, phenelzine, tramadol, tranylcypromine |
Adjunctive therapy | First-line: aripiprazole, risperidone Second-line: memantine, quetiapine, topiramate Third-line: amisulpride, celecoxib, citalopram, granisetron, haloperidol, IV ketamine, mirtazapine, N-acetylcysteine, olanzapine, ondansetron, pindolol, pregabalin, riluzole, ziprasidone Not recommended: buspirone, clonazepam, lithium, morphine |
Not recommended | Clonazepam, clonidine, desipramine |
Medication | Dose |
---|---|
Clomipramine | 150-250mg PO daily[35] |
Fluoxetine | 20-80mg PO daily |
Fluvoxamine | 150-300mg PO daily |
Sertraline | 100-200mg PO daily |
Paroxetine | 20-80mg PO daily |
Escitalopram | 10-50mg PO daily* |
Citalopram | 20-80mg PO daily* |
Guideline | Location | Year | Website | |
---|---|---|---|---|
Canadian Clinical Practice Guidelines | Canada | 2014 | - | Link |
National Institute for Health and Care Excellence (NICE) | UK | 2005 | - | Link |
American Psychiatric Association (APA) | USA | 2007, 2013 | - | • Guideline (2007) • Guideline Watch (2013) • Quick Reference |