Obsessive-compulsive disorder

What is it?

This disorder is characterized by recurrent obsessions or compulsions that take up a significant amount of the person's life. The obsessions or compulsions are distressing, take at least an hour a day, and/or cause significant interference in the personal, social, or occupational life of the individual. It may lead to avoidance of the situations associated with the obsession or compulsion; for example, a person concerned about dirt may avoid public restrooms or even shaking hands with others. The obsessions are recognized as being excessive or unreasonable. Obsessions are repetitive thoughts or images that recur over and over, are unwelcome, and cause anxiety. Common obsessions include concerns about becoming dirty, concerns about having done something (such as having hurt someone) or not done something (left a door unlocked), or sexual thoughts and images. These concerns are not related to real-life, identifiable problems.

A compulsion is a repetitive action, which is thought to relieve the anxiety over an obsession. It usually must be performed over and over according to strict rules. For example, obsession with becoming dirty can lead to repetitive hand washing, and fear over leaving a door unlocked can result in checking and rechecking the lock every few minutes.

The obsessions and compulsions are experienced as foreign to the individual's personality, with an unpleasant and uncomfortable quality about them. They are not the kind of thoughts the person would expect to be having.

This disorder can be seen in two percent of the population at some time during their lives, with males and females affected equally. Onset is usually gradual, beginning in adolescence or early adulthood, but can also begin in childhood. Over half of individuals develop symptoms after a very stressful event, but they do not usually seek psychiatric help until five or ten years later.

Sometimes behaviors such as gambling, drinking, or sexual activity are termed "compulsive." However, in these cases, the behavior is experienced as pleasurable, and is not done to defend against an obsession.

This diagnosis is not made if it occurs solely in conjunction with another psychiatric disorder, or if due to a medication, drug or alcohol abuse, or a medical condition.

How is it diagnosed?

History is of either obsessions or compulsions or both. An obsession is a recurring thought or image that intrudes on the person's consciousness, and is at some time experienced as inappropriate. The obsession does not appear related to a real life event. There is an attempt either to suppress the persistent thought or to negate it with another thought or an action. The obsession is experienced as coming from the person's own mind and not from some external source. A compulsion is a behavior that is done repeatedly. The individual with this disorder realizes at some point that the obsessions or compulsions are unreasonable. The obsessions or compulsions consume more than one hour each day, or interfere with personal, social, academic, or occupational functioning.

Physical exam could show skin changes from repeated washing, if that compulsion is present.

Tests are not diagnostic.

How is it treated?

Drug therapy combined with behavioral therapy is most effective. Drug therapy is usually a serotonin-specific reuptake inhibitor (SSRI), antidepressant, or a tricyclic antidepressant.

Behavior therapy exposes the person to their fears in order to reduce the anxiety surrounding the obsessions. Response prevention strategies are then developed to gradually delay performing the compulsive ritual, eventually eliminating it altogether. The individual must be truly committed in order to comply with this therapy, due to its stressful nature. The therapy may be done as an outpatient or inpatient. Family therapy is useful, because this disorder is quite stressful to family members. Insight-oriented psychotherapy is infrequently helpful.

Medications

Information	Brand	Generic	Label	Rating
	Paxil	Paroxetine
	Effexor	Venlafaxine
	Zoloft	Sertraline

Celexa (Citalopram), Luvox (Fluvoxamine), Prozac (Fluoxetine), Remeron (Mirtazapine), Seroquel (Quetiapine), Xanax (Alprazolam)

What might complicate it?

One-third will develop a major depressive episode, and suicide is a risk. Tics may appear.

Predicted outcome

This disorder usually runs a chronic course, with periods of improvement and worsening. Twenty percent of people will improve significantly with treatment, half will have some improvement, and the remainder will stay the same or become more disturbed. Approximately fifteen percent show a gradually progressive deterioration in functioning.

Alternatives

Other anxiety disorders could be from drug abuse or a medical condition, a specific phobia, generalized anxiety disorder, delusional disorder or schizophrenia (if psychotic features are present), eating disorder, sexual disorder, or obsessive-compulsive personality disorder.

Appropriate specialists

Psychiatrist or psychologist.

Last updated 20 December 2015