2.1.7 Obsessive Compulsive Disorder
Obsessive Compulsive Disorder
Obsessive-Compulsive Disorder (OCD) is a common and chronic condition characterized by obsessions and compulsions causing significant distress and interference with social or individual functioning. It is often associated with marked anxiety and depression, and the symptoms must not be the result of another psychiatric disorder. At some point in the disorder, the person recognizes the symptoms to be excessive or unreasonable.
Prevalence/Incidence:
OCD has a lifetime prevalence estimated to be around 2% (0.5-3%)globally.
The mean age of onset for OCD is 20 years old, with 70% of cases starting before the age of 25 years old and only 15% starting after age 35. The condition affects males and females equally.
Aetiology:
Like anxiety disorders, OCD is thought to have a complex aetiology involving genetic, environmental, and psychological factors. Neuroimaging studies have suggested abnormalities in the cortico-striatal-thalamo-cortical circuitry as well as abnormalities in serotonin transmission.
Presentation:
OCD is characterized by intrusive, distressing thoughts (obsessions) and repetitive behaviours or mental acts (compulsions) that are performed to reduce anxiety associated with the obsessions.
Treatment:
The first-line treatment for OCD is CBT, specifically exposure and response prevention (ERP), with or without medication, such as SSRIs.
OCD management includes psychological and pharmacological treatments, as well as physical interventions in severe cases. Psychological treatments involve cognitive-behavioural therapy (CBT), behavioural therapy, cognitive therapy, and supportive psychotherapy. Pharmacological treatments include SSRIs and other antidepressants, augmentative strategies such as antipsychotics and anxiolytics, and other adjunctive agents. Physical treatments like ECT and psychosurgery are reserved for severe, treatment-resistant cases, while the efficacy of deep brain stimulation (DBS) is still being established.
| Treatment Category | Treatment Type | Treatment Name | Dose Range | Notes |
| Psychological | CBT | NICE-recommended; includes exposure and response prevention | ||
| Behavioural Therapy | Useful in ritualistic behaviour and ruminations | |||
| Cognitive Therapy | Not proven effective | |||
| Psychotherapy | Supportive | Valuable; includes family members and use of groups | ||
| Psychoanalytical | No unequivocal evidence of effectiveness | |||
| Pharmacological | Antidepressants | Escitalopram | 10–20mg/day | First-line treatment |
| Fluoxetine | 20–60mg/day | First-line treatment | ||
| Fluvoxamine | 100–300mg/day | First-line treatment | ||
| Sertraline | 150mg/day | First-line treatment | ||
| Paroxetine | 40–60mg/day | First-line treatment | ||
| Clomipramine | 250–300mg | Second-line treatment (NICE) | ||
| Citalopram | 20–60mg/day | Unlicensed, NICE-recommended alone or with clomipramine | ||
| Venlafaxine | 225–300mg | Unlicensed | ||
| Augmentative | Risperidone | Not specified | Antipsychotic, for psychotic features, tics, schizotypal traits | |
| Strategies | Haloperidol | Not specified | Antipsychotic, for psychotic features, tics, schizotypal traits | |
| Pimozide | Not specified | Antipsychotic, for psychotic features, tics, schizotypal traits | ||
| Buspirone | Not specified | Not NICE-recommended, for marked anxiety | ||
| Clonazepam | Short-term use | Not NICE-recommended, for marked anxiety | ||
| Adjunctive | Mirtazapine | 15–30mg | ||
| Agents | Lamotrigine | 100mg/day | ||
| Topiramate | 100–200mg/day | |||
| Memantine | 20mg/day | |||
| Celecoxib | 400mg/day | |||
| Dexamfetamine | 30mg/day | |||
| Caffeine | 300mg/day | |||
| Physical | ECT | For suicidal or severely incapacitated patients | ||
| Psychosurgery | Stereotactic Cingulotomy | For severe, incapacitating, intractable cases | ||
| DBS | Efficacy remains to be established; for severe refractory cases |
Outcome:
OCD often begins suddenly, typically following a stressful event such as a loss, pregnancy, or sexual issue. However, the presentation can be delayed by 5 to 10 years due to the individual’s secrecy about their symptoms. The intensity of symptoms may vary, either fluctuating or remaining chronic.
Improvement in OCD patients varies 20-30% experience significant improvement, 40-50% showed moderate improvement, and 20-40% face chronic or worsening symptoms. Relapse rates are high after discontinuing medication, and suicide rates are increased, especially in cases of secondary depression.
Summary
| OCD | |
| Prevalence | 2% |
| Onset | Typically in childhood or adolescence |
| Gender | Males are more likely than females to experience OCD |
| Aetiology | Genetic and environmental factors |
| Presentation | Obsessions and compulsions that interfere with daily life |
| Treatment | CBT, medication (SSRIs), ECT |
| Outcome | Significant symptom improvement and functional recovery with good management but figures vary. |
References:
- Semple, D., Smyth, R., & Burns, J. (Eds.). (2019). Oxford handbook of psychiatry (4th ed.). Oxford University Press.