Substance/Medication-Induced Obsessive-Compulsive and Related Disorder

Substance/Medication-Induced Obsessive-Compulsive and Related Disorder is an obsessive-compulsive and related disorder that is diagnosed after an individual uses a substance (e.g. - a drug of abuse, a medication, or a toxin exposure) that leads to prominent symptoms of an obsessive-compulsive and related disorder.

• The prevalence is difficult to estimate and thought to be very rare.^[1]

Obsessions, compulsions, skin picking, hair pulling, other body-focused repetitive behaviours, or other symptoms characteristic of the obsessive-compulsive and related disorders predominate in the clinical picture.

There is evidence from the history, physical examination, or laboratory findings of both (1) and (2):

1. The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication.
2. The involved substance/medication is capable of producing the symptoms in Criterion A.

The disturbance is not better explained by an obsessive-compulsive and related disorder that is not substance/medication-induced. Such evidence of an independent obsessive-compulsive and related disorder could include the following:

• The symptoms precede the onset of the substance/medication use; or
• The symptoms persist for a substantial period of time (e.g. - about 1 month) after the cessation of acute withdrawal or severe intoxication; or
• There is other evidence suggesting the existence of an independent non-substance/medication-induced obsessive-compulsive and related disorder (e.g. - a history of recurrent non-substance/medication-related episodes).

The disturbance does not occur exclusively during the course of a delirium.

The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

• Obsessions, compulsions, hair pulling, skin picking, or other body-focused repetitive behaviours can occur in association with intoxication with stimulants (including cocaine) and other (or unknown) substances.
• Heavy metals and toxins may also cause obsessive-compulsive and related disorder symptoms.^[2]

• There is emerging evidence that second-generation antipsychotics, in particular clozapine and olanzapine, can cause de novo obsessive compulsive symptoms (not disorder) or exacerbate pre-existing symptoms.^[3][4]
• Stimulant medications for ADHD may also exacerbate obsessive compulsive or cause de novo symptoms.^[5]

• Substance intoxication
  • Obsessive-compulsive and related disorder symptoms may occur in substance intoxication. The diagnosis of the substance-specific intoxication will usually enough to categorize the symptom presentation. A diagnosis of an obsessive-compulsive and related disorder should be made in addition to substance intoxication when the symptoms are judged to be in excess of those usually associated with intoxication and are sufficiently severe to warrant independent clinical attention.
• Obsessive-compulsive and related disorder (i.e. - not induced by a substance)
  • Substance/medication-induced obsessive-compulsive and related disorder is distinguished from a primary obsessive-compulsive and related disorder by considering the onset, course, and other factors with respect to substances/medications. For drugs of abuse, there must be evidence from the history, physical examination, or laboratory findings for use or intoxication. Substance/medication-induced obsessive-compulsive and related disorder arises only in association with intoxication, whereas a primary obsessive-compulsive and related disorder may precede the onset of substance/medication use. The presence of features that are atypical of a primary obsessive-compulsive and related disorder, such as atypical age at onset of symptoms, may suggest a substance-induced etiology. A primary obsessive-compulsive and related disorder diagnosis is warranted if the symptoms persist for a substantial period of time (about 1 month or longer) after the end of the substance intoxication or the individual has a history of an obsessive-compulsive and related disorder.
• Obsessive-compulsive and related disorder due to another medical condition
  • If the obsessive-compulsive and related disorder symptoms are attributable to another medical condition (i.e. - rather than to the medication taken for the other medical condition), obsessive-compulsive and related disorder due to another medical condition should be diagnosed. The history often provides the basis for judgment. Sometimes, a change in the treatment for the other medical condition (e.g. - medication substitution or discontinuation) may be needed to determine whether or not the medication is the causative agent (in which case the symptoms may be better explained by substance/medication-induced obsessive-compulsive and related disorder).
• Delirium
  • If obsessive-compulsive and related disorder symptoms occur exclusively during the course of delirium, they are considered to be an associated feature of the delirium and are not diagnosed separately.

• Urine drug screens may be useful to assess substance intoxication as part of an assessment for obsessive-compulsive and related disorders.