Obsessive-Compulsive Disorder: Over and Over
Obsessive-Compulsive Disorder: Over and Over
Authors:
Randy A. Sansone, MD, Professor, Departments of Psychiatry and Internal Medicine, Wright State University School of Medicine, Dayton, OH; Director of Psychiatry Education, Kettering Medical Center, Kettering, OH.
Lori A. Sansone, MD, Medical Director, Primary Care Clinic, Wright Patterson Air Force Base, Dayton, OH.
The views and opinions expressed in this article are those of the authors and do not reflect the official policy or position of the US Air Force, Department of Defense, or US Government.
Peer Reviewer:
Glenn W. Currier, MD, MPH, Associate Professor, Psychiatry and Emergency Medicine, University of Rochester, New York.
Obsessive-compulsive disorders have achieved greater visibility in our society with several well-known celebrities such as Howie Mandel and David Beckham with acknowledged cases. Patients may be reluctant to share their symptoms with their primary care physician for fear of being thought crazy. Hopefully today the increased recognition with celebrities and greater media attention to the disorder will resolve this fear and allow patients to become more open with their doctors. It has become increasingly apparent that severe symptoms can markedly interfere with individuals' enjoyment of life and adversely affect social and professional relationships. The following illustrates a hypothetical case:
P.W. is a 25-year-old single woman who seeks treatment for anxiety and depressive symptoms. In college she was an accounting major and had a compulsion to have each page of her assignments perfectly done with no erasures or mistakes. This compulsion occasionally led to considerable anxiety and academic pressures, which interfered with her social life, but she received excellent grades. Upon graduation she was able to obtain a job in claims processing at a local managed care organization. At the managed care organization, her responsibilities included payment of physician claims. She compulsively reviewed claims for any errors and made sure that the physicians on her panel were paid fully and promptly. She often went back after hours to be sure that the claims were being processed properly. She would often go the extra mile and contact accounts payable to be sure that the physicians were being paid their full amount by contract. She sought clinical help from one of the physicians in her panel. Despite his seeing her weekly for more than a year and his billing comprehensive CPT codes for each visit, the physician was inexplicably not able to resolve her compulsive behavior at work. Surprisingly, when she changed physicians and saw a primary care physician not on her panel, her symptoms improved markedly with appropriate therapy.
Obviously this is a fictitious case that perhaps has never been seen in the clinical literature, but many physicians may secretly have wished to have such a therapeutic challenge in their practice just once. In real life, for many patients with obsessive-compulsive disorders, their symptoms are disabling. Treatment can be quite effective if primary care physicians can readily identify these patients and then initiate appropriate cognitive and/or pharmacologic intervention. This issue outlines the prevalence, pathophysiology, diagnostic tools, and therapeutic options that are available today for primary care physicians.
The Editor
Introduction
Once a highly secretive and poorly understood syndrome, obsessive-compulsive disorder (OCD) is gaining increasing visibility with the general public. A number of factors appear to be contributing to the heightened awareness of this fascinating disorder. First, several celebrities have disclosed their personal struggles with OCD. For example, Howie Mandel, a Canadian-born comedian and actor, revealed his intense fears of contamination by others. In response to these illogical fears, Mr. Mandel stringently avoids shaking hands unless he is wearing latex gloves.1 David Beckham, a well-known UK soccer star, admitted that he suffers from OCD, which in his case is characterized by an intense need for symmetry and orderliness.2 In response to these preoccupations, he compulsively rearranges motel rooms and soda cans in the refrigerator to "make everything perfect." Jennifer Love Hewitt, a well-known American actress ("I Know What You Did Last Summer," "Ghost Whisperer"), recently acknowledged her fear of going to sleep before all of her closet and cabinet doors are closed.3 The personal revelations of these and other renowned public figures have genuinely contributed to public awareness as well as the de-stigmatization of OCD.
In addition to celebrity disclosures, the media has integrated various OCD themes into a number of commercial ventures. For example, in the film "As Good As It Gets," Jack Nicholson plays Melvin Udall, a dysphoric and despondent man who eats in the same restaurant every day and must compulsively use his own disposable plastic food utensils in order to avoid contracting the germs of others. In "The Aviator," Leonardo DiCaprio plays the eccentric Howard Hughes, a character who in the movie compulsively repeats phrases over and over and exhibits an intense fear of dust and germs. In addition to the preceding movie ventures, the television series "Monk" boldly unveiled a main character who suffers from severe OCD. In this series, Tony Shalhoub expertly plays the role of Adrian Monk, a private detective who suffers from an all-encompassing fear of germs and cups as well as a host of other phobias. Finally, during the year 2009, A&E Television debuted a docuseries solely anchored on the subject of OCD entitled "Obsessed."
OCD has also been receiving more positive public exposure through Elizabeth McIngvale, a young charismatic Houston resident who is presently the spokesperson for the International OCD Foundation and also suffers from OCD. At one point in her course of illness, Ms. McIngvale was washing her hands 100 times per day and was assessed by professionals as untreatable.
While all of the preceding developments have clearly contributed to the public face of OCD, the disorder still remains highly elusive and under-diagnosed. In this edition of Primary Care Reports, we will review the clinical features, diagnosis, and treatment of OCD.
The Psychiatric Criteria for OCD
In the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR),4 OCD is classified as an Axis I disorder (i.e., a major psychiatric disorder) and is allocated to the symptom category of anxiety disorders. To be diagnosed with OCD, an individual must experience either obsessions or compulsions. (See Table 1.)4
Table 1: The Diagnostic Criteria for Obsessive-Compulsive Disorder, According to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision4
The individual must exhibit either:
1. Obsessions, characterized by:
a) Recurrent and persistent thoughts, impulses, and images that are experienced as intrusive and inappropriate, and that cause marked anxiety and/or distress
b) Not simply being excessive worries about real-life situations
c) The individual's counteractive response, such as ignoring, suppressing, and/or neutralizing the obsession with some other thought and/or action
d) The individual's recognition that they are a product of his/her own mind
2. Compulsions, characterized by:
a) Repetitive behaviors or mental acts in response to an obsession and in accordance with internal rules
b) The functional purpose of reducing stress or a dreaded outcome, despite being illogically designed for this purpose
The individual:
1. Recognizes that the obsessions and/or compulsions are unreasonable
2. Experiences the obsessions and/or compulsions as distressing and time-consuming (i.e., they take more than one hour per day), and as causing some degree of functional impairment
3. Does not have obsessions/compulsions limited to a comorbid Axis I disorder (e.g., trichotillomania, eating disorders)
4. Does not have symptoms that can be attributable to a substance or general medical condition
Obsessions
Obsessions are recurrent, persistent, intrusive, and inappropriate thoughts, impulses, or images that the sufferer recognizes are illogical and a product of his/her own mind (i.e., the content is ego-dystonic). As emphasized in the DSM-IV-TR,4 clinical obsessions go well beyond the margins of everyday excessive worries, which is clarified by the descriptor "inappropriate." In addition, the sufferer must reflexively make active attempts to ignore, suppress, or neutralize these disturbing thoughts, impulses, and/or images through counteractive thoughts and actions. For example, an adolescent male patient described his recurrent and unrelenting fear of impregnating female partners in the absence of overt sexual contact. While he logically understood that impregnation under these circumstances was impossible, he was plagued by his illogical fear and doubt. In addition, a male school teacher reported that under stress, he experienced severely disturbing and illogical religious thoughts, which he never disclosed to anyone because of his fears of embarrassment. Up to 55% of individuals with OCD (average of around 20%) have a pure obsessional version of OCD (i.e., there are no identifiable compulsions).5
Compulsions
In contrast to the purely mental substrate of obsessions, compulsions are physical or mental actions that develop in order to counteract the perceived perils of distressing obsessions.4 In other words, compulsions are repetitive behaviors or mental acts that function to psychologically neutralize obsessions (i.e., they reduce or prevent distress or some catastrophized outcome).4 Although these counteracting behaviors and mental acts are not logically and rationally able to successfully execute these functions, they are nonetheless compellingly performed, oftentimes with extreme excessiveness. A classic example of counteractive compulsive behavior is repetitive hand washing, which is typically in response to intense and illogical fears of personal contamination. As for other examples, a college-age female described her irrational fixation with clothing and jewelry. On days of severe stress, she obsessively associated the "bad day" with the clothing and jewelry that she wore that day. As a result, she would no longer wear these articles, which were meticulously stored but never relinquished. A male patient expressed his irrational fear of having run over someone while driving a car, despite not seeing anyone in the street or experiencing any impact. This fear resulted in his counteractive compulsion of checking for a bodyi.e., reviewing his route of travel several times in search of the elusive corpse. Finally, a middle-aged male professional disclosed his compulsive need to move his foot through a perfect square for a specific number of times in order to alleviate acute anxiety.
Symptom Clusters/Subgroups
The obsessions and compulsions of OCD may take numerous phenotypic forms, making specific symptom identification challenging. However, a number of investigators have assessed OCD symptoms in various types of study populations and determined the most common symptom dimensions, symptom clusters, or clinical subtypes.6-10 In doing so, the resulting symptom clusters potentially provide clinicians with high-yield areas of specific symptom inquiry. Several examples of commonly identified symptom clusters are shown in Table 2.
Table 2: Examples of Symptom Clusters Identified in Studies of Participants with Obsessive-Compulsive Disorder5-9
|
First Author |
Year of Publication |
Identified Symptom Cluster |
|
Calamari6 |
1999 |
Harming, hoarding, contamination, uncertainty, obsessionalism |
|
Denys7 |
2004 |
Contamination/cleaning, sexual/religious/somatic obsessions and checking; high-risk assessment and checking; frightening impulses and fears of losing control; symmetry, exactness/ordering, and counting; rumination |
|
Cullen8 |
2007 |
Pure obsessions, contamination, symmetry/ordering, hoarding |
|
Lochner9 |
2008 |
Contamination/washing; hoarding/symmetry/ordering; obesessionalism/checking |
|
Bloch10 |
2008 |
Symmetry, forbidden thoughts, cleaning, hoarding |
In addition to phenotypic variability, there may be some subtle gender differences with regard to OCD symptom clusters. For example, in a Spanish study, investigators found gender differences in two specific symptom domains i.e., contamination and cleaning were more common in women, whereas sexual and religious themes were more common in men.11
An Ever-elusive Diagnosis in the Clinical Setting
In primary care and psychiatric settings, patients with OCD rarely disclose their troubling symptoms at the initial appointment. A patient's resistance to the revelation of these bizarre thoughts and behaviors is probably related to the paradox of unreasonable symptoms in a reasonable mind, which understandably results in the individual's fear of being perceived by others as "crazy." Thus, OCD clinically remains an elusive disorder. Instead, OCD patients frequently present in treatment settings with adjunctive psychiatric concerns, such as anxiety and depressive symptoms. These presenting psychological concerns may need to be briefly tilled by the clinician for underlying OCD symptoms (i.e., the clinician may need to initiate an active inquiry, particularly when clues are present), with an emphasis on "repetitive" and "illogical" thoughts and behaviors. "With your anxiety, do you ever experience any repetitive and illogical thoughts? With your anxiety, do you ever experience any repetitive and illogical behaviors?" In addition to direct query, depending on the compulsion, there may be physical evidence of performance excess (e.g., raw and excoriated hands from excessive hand washing).
Epidemiology
Prevalence. According to the findings of the National Comorbidity Survey Replication, which was a community study of the prevalence of various psychiatric disorders in a nationally representative U.S. sample, the lifetime prevalence of OCD is 1.6%.12 Through a recent re-analysis of these data, the lifetime prevalence is now estimated at 2.3%.13 As for primary care settings, in a consecutive sample of 108 anxious and depressed family practice patients, investigators determined the prevalence of OCD at 3% (in this study, there were no data on the prevalence of OCD in a consecutive sample of presenting family practice patients, nor could we locate in the empirical literature any alternative prevalence rates in primary care settings).14
Onset and Gender Patterns. The mean age-of-onset of OCD is around 19.5 years.13 With nearly a quarter of males with OCD experiencing symptom onset before age 10, males clearly predominate in early-onset cases.13 The onset of OCD symptoms after the age of 30 years is very uncommon,13 although once established, the course of illness tends to be longstanding.15
Psychiatric Comorbidity. Up to 90% of individuals with OCD suffer from comorbid psychiatric disorders (i.e., OCD is highly comorbid with other psychiatric symptoms).13 Research indicates that 75.8% of OCD sufferers have anxiety disorders, 63.3% mood disorders, 55.9% impulse-control disorders, and 38.6% substance-use disorders.13 Note that OCD rarely exists independent of other psychiatric disorders and, again, these adjunctive disorders may constitute the initial symptoms presented by the patient.
Etiology
The etiology of OCD is believed to be due to the variable interaction of genes and the environment.16-18 Genetic contributions have been confirmed through family, twin, and segregation-analysis studies.17 In comparison with late-onset OCD, early-onset OCD may be particularly influenced by family genetics.18 While specific chromosomal regions have been linked to OCD and several candidate genes have been identified, no specific genes have been conclusively confirmed.19
Pathophysiology
The explicit pathophysiology of OCD has yet to be elucidated and may be complicated by variations in genetics and OCD subtypes. However, the neurotransmitter serotonin (the classic neurotransmitter associated with OCD) as well as dopamine and GABA all appear to be implicated in this disorder.20 In addition, immunological alterations may be present20 as well as abnormalities in the cingulate cortex, orbitofrontal cortex, thalamus, and basal ganglia.21 Again, how these various abnormalities inter-relate is not explicitly known.
Clinical Diagnosis
Patient Assessment. Troublesome obsessions and/or compulsions are the key clinical features in OCD. However, as noted before, at presentation the patient may couch these symptoms in other psychiatric complaints, such as anxiety and/or depression. OCD may be teased out by exploring the presence of any "repetitive" and "illogical" thoughts and behaviors. In addition, familiarity with the common symptom clusters noted in Table 2 may expedite the identification of specific symptoms by focusing on high-yield areas of inquiry.
Diagnostic Tools. In those cases with a high index of suspicion but not a clear diagnosis, a self-report screening measure may be useful. One tool is The Florida Obsessive Compulsive Inventory (FOCI), a self-report measure composed of a 20-item symptom checklist and a 5-item severity scale. If one or more items are endorsed on the symptom checklist, the individual is instructed to complete the severity scale. The FOCI is used for screening; a diagnosis of OCD must be confirmed by clinical interview.22 (See Table 3.)
Table 3: The Florida Obsessive-Compulsive Inventory
Yes No
Have you been bothered by unpleasant thoughts or images that repeatedly enter your mind, such as:
___ ___ 1. Concerns with contamination (dirt, germs, chemicals, radiation) or acquiring a serious illness such as AIDS?
___ ___ 2. Overconcern with keeping objects (clothing, groceries, tools) in perfect order or arranged exactly?
___ ___ 3. Images of death or other horrible events?
___ ___ 4. Personally unacceptable religious or sexual thoughts?
Have you worried a lot about terrible things happening, such as:
___ ___ 5. Fire, burglary, or flooding of the house?
___ ___ 6. Accidentally hitting a pedestrian with your car or letting it roll down the hill?
___ ___ 7. Spreading an illness (giving someone AIDS)?
___ ___ 8. Losing something valuable?
___ ___ 9. Harm coming to a loved one because you weren't careful enough?
Have you ever worried about acting on an unwanted and senseless urge or impulse, such as:
___ ___ 10. Physically harming a loved one, pushing a stranger in front of a bus, steering your car into oncoming traffic; inappropriate sexual contact; or poisoning dinner guests?
Copyright © 1994 Dr. Wayne Goodman. Used with permission.
Above is a reproduction of the first 10 items on the Florida Obsessive-Compulsive Inventory (FOCI). The full scale incorporates an additional 10 items assessing compulsions, as well as a five-item severity scale. For a copy of the entire measure, please contact Dr. Goodman [email protected].
As for a clinician-administered assessment that both detects symptoms and assesses their severity, the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) is an option.23,24 The Y-BOCS is a classic measure in the field of OCD and, through serial evaluations, enables clinicians to assess clinical improvement in a standardized manner (i.e., the measure can be used to track symptom clusters over time). Composed of both a symptom checklist and a severity scale, this measure recently underwent a revision and has emerged as the Y-BOCS-II.25
As a web-based alternative, The Panic Center offers a free-of-charge self-report screening assessment, the Web-Based Depression and Anxiety Test, at http://www.paniccenter.net/wbdat/default.aspx.26 This assessment tool screens not only for OCD but also comorbid syndromes such as depression and anxiety, including panic, generalized anxiety, social anxiety, and post-traumatic stress disorders.
For cases that remain inconclusive despite assessment, consultation with a psychiatrist is indicated.
Differential Diagnosis
The symptoms of OCD are oftentimes nested with other anxiety and mood disorders. Therefore, while the features of OCD are fairly cogent, diagnosis may be complicated by the presence of distracting adjunctive symptoms. In addition, several clinical syndromes appear to have similar psychological themes. In this regard, two particular types of maladies are especially relevant.
Obsessive-Compulsive Personality Disorder. With a prevalence rate of 8% in the general U.S. population, obsessive-compulsive personality disorder (OCPD) is the most common personality dysfunction in this country.27 According to the DSM-IV-TR,4 OCPD is characterized by a pervasive pattern of orderliness, perfectionism, and mental and interpersonal control, which occurs at the expense of flexibility, openness, and efficiency. The eight DSM-IV-TR criteria for OCPD are show in Table 4.4 Note that preoccupation with order and organization as well as hoarding are symptoms that conceptually overlap with OCD.
Table 4: The Diagnostic Criteria for Obsessive-Compulsive Personality Disorder, According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision4
At least four of the following are required:
- Preoccupation with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost
- Perfectionism that interferes with task completion
- Excessive devotion to work and/or productivity to the exclusion of leisure activities and/or friendships
- Over-conscientiousness, scrupulousness, and/or inflexibility with regard to morality, ethics, or values
- Inability to discard worn-out clothes or worthless objects, even though they have no sentimental value
- Reluctance to delegate tasks or work with others unless they submit exactly to his/her way of doing things
- Adoption of a miserly spending style with regard to self/others
- Rigid, stubborn
To confound matters, OCD and OCPD may coexist together. In a meta-analysis, Mancebo and colleagues found that 25% of patients with OCD have comorbid OCPD, and 20% of OCPD patients have comorbid OCD.28 According to some research, patients with both disorders may have an earlier onset of OCD symptoms as well as greater psychosocial impairment, and may represent a specific subtype of OCD.29
Despite the observed overlap and some similar characteristics (e.g., perfectionism,30 early age-of-onset, doubting), there appear to be a number of distinct clinical differences between OCD and OCPD, as well. For example, in OCD, the symptoms are oftentimes perceived by the sufferer as morally repugnant urges that are unacceptable, illogical, and/or inappropriate (i.e., ego-dystonic) whereas in OCPD, the symptoms are typically perceived by the sufferer as useful, necessary, and potentially beneficial (i.e., ego-syntonic). As a result, OCD generates greater overall mental discomfort than OCPD, and OCD is more often associated with serious social and occupational impairment.31 These disorders are compared and contrasted in Table 5. Despite these seemingly patent differences, the two disorders can be challenging at times to differentiate in the clinical setting.
Table 5: Obsessive-Compulsive Disorder (OCD) versus Obsessive-Compulsive Personality Disorder (OCPD): Similarities and Differences
|
Characteristic |
OCD |
OCPD |
|
Onset |
Oftentimes early |
Early |
|
Perfectionism |
Present |
Present |
|
Self-imposed structure |
Based on idiosyncratic rules |
Oftentimes based on distortions of perceived social rules |
|
Orderliness/organization |
Possibly present |
Possibly present |
|
Hoarding |
Possibly present |
Possibly present |
|
Familial presence |
Present |
Present |
|
Obsessions |
Present |
Absent |
|
Compulsions |
Present |
Absent |
|
Symptom perception |
Great mental discomfort |
Acceptable |
|
Course |
> Social/occupational impairment |
< Social/occupational impairment |
|
Symptom response to medications |
Key symptoms affected (i.e., obsessions/compulsions) |
Adjunctive symptoms affected (e.g., worry) |
Obsessive-Compulsive Spectrum Disorders. Clinical syndromes characterized by repetitive thoughts and/or behaviors have been described as obsessive-compulsive spectrum disorders. These include trichotillomania (i.e., the recurrent and compulsive pulling out of one's own hair, resulting in observable hair loss), body dysmorphic disorder (i.e., an obsessive and irrational preoccupation with a minor or non-existent defect in one's physical appearance), skin picking (i.e., the repetitive picking of one's own skin to the extent that it causes damage), and hypochondriasis (i.e., the obsessive and irrational fear of having a serious disease or medical condition). At the present time, the DSM-IV-TR4 explicitly states that if another Axis I disorder is present (e.g., body dysmorphic disorder), in order to meet the criteria for OCD, the content of the obsessions or compulsions cannot be restricted to it. According to Hollander and colleagues, many obsessive-compulsive spectrum disorders share profound similarities with OCD, including phenomenology, comorbidity, familial predisposition/genetics, and treatment responses to psychotropic medication.32
The Treatment of OCD
Following the diagnosis of OCD, there are two general treatment approaches pharmacotherapy and psychotherapy.
Pharmacotherapy. Selective Serotonin Reuptake Inhibitors. According to the Practice Guideline for the Treatment of Patients with Obsessive-Compulsive Disorder (referred to from this point forward as the Practice Guideline),33 first-line medications for the treatment of OCD are the selective serotonin reuptake inhibitors (SSRIs). While each is structurally unique, all SSRIs block the reuptake of serotonin and appear to be equally effective in the treatment of OCD. Only fluoxetine (1994), fluvoxamine (1994), paroxetine (1996), and sertraline (1997) have FDA-approved indications for OCD.
The Practice Guideline recommends beginning SSRI treatment at the usual starting dose recommended by the manufacturer and then titrating the dose upward.33 Available data suggest that higher SSRI doses produce a greater response rate (i.e., in many cases, the dosage will need to be gradually titrated to the upper end of the therapeutic range if not higher, as tolerated).33 Starting and usual OCD-treatment doses for the SSRIs are shown in Table 6.33 Because many outpatients are more sensitive to the potential side effects of psychotropic drugs than severely ill psychiatric inpatients, we suggest a starting dose that is half of that recommended in Table 6, with a gradual titration to the recommended usual target dose.33 Drug-evaluation trials for OCD are 10-12 weeks in duration.33
Table 6: Typical Starting and Target Doses of Selective Serotonin Reuptake Inhibitors (SSRIs) in the Treatment of Obsessive-Compulsive Disorder33
|
SSRI |
Starting Dose* (mg per day) |
Usual Target Dose (mg per day) |
|
Citalopram |
20 |
40-60 |
|
Escitalopram |
10 |
20 |
|
Fluoxetine |
20 |
40-60 |
|
Fluvoxamine |
50 |
200 |
|
Paroxetine |
20 |
40-60 |
|
Sertraline |
50 |
200 |
|
* For outpatients, start at half this dose to reduce side effects. |
||
The most common side effects of SSRIs are gastrointestinal disturbances, headaches, activation or sedation, and sexual dysfunction (e.g., decreased libido, difficulty with erection and orgasm).33 These side effects can be minimized by starting at low doses and pursuing a gradual course of titration. With the exception of sexual dysfunction, the remaining side effects are usually minimal and fleeting and do not usually preclude successful therapy. With problematic sexual dysfunction, a trial with an alternative SSRI or non-SSRI may be necessary.
As for potential differences among the SSRIs, fluoxetine tends to be more activating than the others. Sertraline may cause loose stools, whereas paroxetine may cause constipation. Paroxetine and fluvoxamine may result in mild sedation. Fluvoxamine has the greatest potential for drug interactions through the P-450 isoenzyme system in the liver. Paroxetine is clinically noted for causing weight gain and is more likely to have a dramatic withdrawal syndrome with abrupt discontinuation. From an overall side-effect perspective, sertraline, citalopram, and escitalopram are especially well tolerated.
Table 7: Patient Resources
- International OCD Foundation: http://www.ocfoundation.org/
- Obsessive-Compulsive Information Center, Madison Institute of Medicine: http://www.miminc.org/aboutocic.asp
- The Austin Center for the Treatment of Obsessive-Compulsive Disorder, recommended resources and readings: http://www.austinocd.com/resources.html
- National Institute of Mental Health, publications about obsessive-compulsive disorder: http://www.nimh.nih.gov/health/publications/ocd-listing.shtml
- Mayo Clinic, obsessive-compulsive disorder: http://www.mayoclinic.com/health/obsessive-compulsive-disorder/DS00189
- Sedaris D. "A plague of tics." Naked. Little Brown & Company; 1987.
Clomipramine. Clomipramine, which affects both serotonin and norepinephrine, is a uniquely effective drug in the tricyclic-antidepressant class for the treatment of OCD. As the first drug approved for the treatment of OCD by the FDA in 1991, clomipramine shares the traditional side effects associated with the other tricyclic antidepressants (i.e., sedation, orthostatic hypotension, tachycardia, anticholinergic effects, weight gain, cardiac arrhythmias in overdose). However, clomipramine is comparable in efficacy to SSRIs in the treatment of OCD.33 Because of the meaningfully higher side-effect load, clomipramine is typically relegated to a second-line (or lower level) medication option. The usual starting dose is 25 mg per day, and the usual target treatment dose is 100-250 mg per day.33 As with the SSRIs, gradual titration is recommended. From a primary care perspective, this antidepressant option may be best deferred to a psychiatrist, given the prevalence of side effects and the high risk of cardiac arrhythmias in overdose.
Serotonin-Norepinephrine Reuptake Inhibitors. Like SSRIs, serotonin-norepinephrine reuptake inhibitors (SNRIs) are neurotransmitter reuptake inhibitors. However, SNRIs block the reuptake of both serotonin and norepinephrine. In the United States, there are currently 4 SNRIs: venlafaxine, desvenlafaxine, duloxetine, and milnacipran. With the exception of desvenlafaxine, which is the active metabolite of venlafaxine, these drugs are structurally different from each other and each individually affects serotonin and norepinephrine to different degrees. For example, both venlafaxine and duloxetine inhibit serotonin reuptake to a greater degree than norepinephrine reuptake, whereas milnacipran exhibits a preference for the reuptake blockade of norepinephine.34
While no SNRI is presently approved by the FDA for the treatment of OCD, there is existing evidence, primarily in case reports and small open-label and double-blind studies, that all of them may be efficacious.35 Importantly, this class of medications may offer both primary care clinicians and psychiatrists a reasonable alternative to SSRIs, which may be complicated by sexual dysfunction, and clomipramine, a side-effect laden tricyclic antidepressant. At the present time, the strongest evidence exists for venlafaxine, which is recommended by the Practice Guideline as an alternative to SSRIs.33 Doses of venlafaxine are initiated at 37.5 mg per day; in studies, final doses have ranged between 225-300 mg per day (i.e., a higher dosage range).36,37
Recommended Pharmacotherapy Approach in Primary Care. Because patients with OCD may at times strongly resist referral to a psychiatrist, the primary care clinician may need to consider undertaking a pharmacological treatment. The Practice Guideline indicates first beginning with an SSRI monotherapy trial.33 Comparing side-effect profiles, we recommend sertraline, citalopram, or escitalopram as the SSRIs of clinical choice. If ineffective, a second SSRI monotherapy trial may be undertaken. After adequate titration, if 10- to 12-week trials of two individual SSRIs are ineffective, we suggest a monotherapy trial with venlafaxine, an SNRI. This simple algorithm is displayed in Figure 1. If these strategies are partially or not effective (only about 70% of patients respond to pharmacological monotherapy38), we suggest referring the patient to a psychiatrist. At this juncture, the psychiatrist may consider clomipramine, augmentation with other medications (e.g., antipsychotics), and/or adjunctive psychotherapy (see below).
Figure 1: Antidepressant Algorithm for the Treatment of Obsessive-Compulsive Disorder in a Primary Care Setting
Black Box Warnings for Antidepressant Use in Children. All antidepressants carry a black-box warning about the risk of suicidal ideation in children ages 18 years or younger. This potential clinical complication is most apparent during the first few months of treatment.34 As always, the clinical need versus risk must be individually assessed in each case. When prescribed in this age group, these patients need to be closely monitored.
Psychological Treatment. In addition to pharmacotherapy, the Practice Guideline33 advocates a specific form of psychotherapy for the treatment of compulsions exposure and response prevention. Exposure and response prevention consists of exposing the patient to the explicit situation that triggers counteractive behavior, and then preventing him/her from engaging in that behavior. This approach is based on the concept that a therapeutic effect will be achieved when the patient confronts his/her fear and discontinues his/her counteractive response. As an example, in the introduction, we noted that Jennifer Love Hewitt cannot relax and go to sleep until all closet and cabinet doors are shut. In this form of treatment, she would be advised to go to bed with all of the closet and cabinet doors fully open and not be permitted to close them. While this form of intervention has good evidentiary support,33 it may be difficult in some communities to find a qualified therapist to administer this specialized treatment.
Summary
OCD affects approximately 2.3% of the general U.S. population. Characterized by distressing obsessions and compulsions, the disorder typically has a mean onset at 19.5 years of age. Patients are typically reluctant to disclose OCD symptoms because of their inherently bizarre content. However, the afflicted may broach the symptoms of a comorbid psychiatric disorder, which is most likely to be an anxiety or depressive disorder. Genetics and their interaction with the environment appear to be etiologic culprits in OCD, and while the exact pathophysiology of the disorder is not clearly established, a number of involved neurotransmitters have been identified as well as specific brain areas of malfunction. In addition to clinical assessment (i.e., exploring "repetitive" and "illogical" thoughts and behaviors), there are existing measures for the assessment of OCD, including a web-based screening measure. In terms of differential diagnosis, OCPD and obsessive-compulsive spectrum disorders may muddy the diagnostic picture.
With regard to treatment, SSRIs are considered first-line medications, and the majority have been approved by the FDA for OCD. The tricyclic antidepressant clomipramine is also approved for the treatment of OCD. While not FDA-approved, there is a developing evidence base for the use of SNRIs in the treatment of OCD, as well. In the primary care setting, we recommend initial trials with sertraline and then citalopram or escitalopram. If unsuccessful, we suggest a trial with venlafaxine. Pharmacological treatment trials are 10-12 weeks in length and the overall response rate is around 70%. As for psychotherapy intervention, exposure and response prevention is recommended for the treatment of compulsions. However, finding qualified therapists to administer this type of treatment can be difficult. In partially or non-responsive cases, we recommend referral to a psychiatrist. OCD can be a challenging disorder to diagnose and treat in the primary care setting. However, a cogent assessment and treatment strategy can result in successful outcomes in these patients.
References
1. Wikipedia. Howie Mandel. Located at: http://en.wikipedia.org/wiki/Howie_Mandel. Accessed on July 13, 2010.
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Obsessive-compulsive disorders have achieved greater visibility in our society with several well-known celebrities such as Howie Mandel and David Beckham with acknowledged cases. Patients may be reluctant to share their symptoms with their primary care physician for fear of being thought crazy. Hopefully today the increased recognition with celebrities and greater media attention to the disorder will resolve this fear and allow patients to become more open with their doctors.Subscribe Now for Access
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