It used to be thought that obsessive-compulsive disorder (OCD) was rare, but it is more common than originally thought. The prevalence is between 2-3% worldwide and it affects males and females equally. Symptoms usually present between childhood and early adulthood, with 75% of patients having symptoms before the age of 18. OCD can be a very debilitating disorder, in terms of the level of impairment and suffering. The term “obsessive-compulsive” is loosely used in everyday jargon, so it is important for providers to be able to detect clinically significant OCD.
In the past, OCD was categorized diagnostically as an anxiety disorder, but in the DSM V it has been separated into its own category. This is largely because research has shown that the genetics of OCD is different from the genetics of other anxiety disorder. OCD is defined as obsessions (intrusive, unwanted and excessive worries) and compulsions (rituals to relieve the anxiety) that are impairing to everyday life. The impairment can be defined by the amount of time spent on the obsessions and compulsions, its effect on preventing a patient from carrying out activities of daily living and work responsibilities, and its effect on alienating important people in the patient’s life. The obsessions and compulsions can involve the following: preoccupation with contamination, cleaning, checking, symmetry and order, preoccupation with sexual, violent or religious thoughts, and hoarding.
The diagnosis of OCD is primarily a clinical one. Two good screening questions to determine if further assessment is indicated are:
- “Are bothered by unpleasant worries that repeatedly come into your mind about contamination, ordering things, etc?
- “Are driven to perform certain acts over and over again like checking locks or washing your hands excessively?”
The YBOCs is a good diagnostic tool for delineating specific symptoms and determining the level of severity and the patient’s level of insight. The patient is typically aware that the obsessions and compulsions are irrational and excessive but are compelled to do them anyways. This egodystonic nature of the illness is partly what leads to the suffering from OCD and can lead to an increased risk of suicide. In rare cases, when patients are not aware that their obsessions and compulsions are irrational and excessive, they are said to have “poor insight” and their OCD is typically more treatment-resistant. These cases can often be difficult to differentiate from true psychotic delusions.
OCD is frequently co-morbid with other anxiety disorders, depressive disorders, and eating disorders in adults and ADHD and tic disorders in children. Treatment options include exposure response prevention (a CBT specifically geared for OCD) and psychotropic medications. ERP involves repeated exposure to situations that trigger the obsessive thoughts and having the patient gradually learn to tolerate the anxiety and resist the urge to perform the compulsions. Medication options include the SSRIs (Prozac, Paxil, Lexapro, Celexa, Zoloft, Luvox) and Anafranil (an older tricyclic antidepressant, used primarily for treatment resistant cases). Medication treatment involves slow titration to avoid worsening the anxiety, and patients often need higher doses for longer periods of time for a full effect. It is important to make sure patients are aware that it can take up to 3 months to get to a full effective dose. Most patients do better with a combination of medication and ERP. There are adjunctive medication options available if full symptom relief is not achieved with an SSRI alone. These include the second-generation antipsychotic medications. Surgery and ECT vs deep brain stimulation can be used for refractory cases.
Given that OCD is more prevalent than previously thought, it is important that first line providers are comfortable with knowing when to assess for OCD and how to pursue with treatment recommendations.