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Monday, August 11, 2025

Obsessive compulsive disorder (OCD)


Introduction
Obsessive–compulsive disorder (OCD) is a chronic psychiatric condition characterized by intrusive, unwanted thoughts (obsessions) and repetitive, ritualistic behaviors or mental acts (compulsions) that an individual feels compelled to perform to reduce anxiety or prevent a feared event. The disorder significantly interferes with daily functioning and quality of life.

Epidemiology

  • Lifetime prevalence: approximately 1–3% worldwide.

  • Mean age of onset: late adolescence to early adulthood; can occur in childhood.

  • Slightly more common in females in adulthood, but more common in males in childhood.

  • Often associated with comorbid conditions such as depression, generalized anxiety disorder, and tic disorders (e.g., Tourette syndrome).

Etiology and Risk Factors

  • Genetic factors: Higher risk in first-degree relatives; heritability estimates range from 40–50%.

  • Neurobiological factors: Dysfunction in cortico-striato-thalamo-cortical (CSTC) circuits; dysregulation of serotonin, dopamine, and glutamate neurotransmitter systems.

  • Environmental factors: Childhood trauma, perinatal complications, or infections (e.g., pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections – PANDAS).

  • Psychological factors: Maladaptive beliefs about responsibility, threat, and control over thoughts.

Clinical Features

Obsessions – Persistent, intrusive thoughts, urges, or images that cause marked distress, such as:

  • Fear of contamination.

  • Unwanted aggressive or sexual thoughts.

  • Excessive concern with symmetry or exactness.

  • Doubts about having harmed others or made mistakes.

Compulsions – Repetitive behaviors or mental acts performed to reduce distress or prevent feared outcomes, such as:

  • Excessive cleaning or handwashing.

  • Checking (locks, appliances) repeatedly.

  • Counting, praying, or repeating words silently.

  • Arranging objects until “just right.”

Insight – Many patients recognize their thoughts and behaviors as excessive or irrational, although insight can vary.

Diagnosis

DSM-5 Criteria:

  • Presence of obsessions, compulsions, or both.

  • Obsessions or compulsions are time-consuming (≥1 hour/day) or cause significant distress/impairment.

  • Symptoms are not attributable to substance use or another medical condition.

  • Disturbance is not better explained by another mental disorder.

Assessment tools:

  • Yale–Brown Obsessive–Compulsive Scale (Y-BOCS) for severity.

Management

General Principles

  • Combination of pharmacotherapy and cognitive-behavioral therapy (CBT) is most effective.

  • Aim for long-term maintenance to prevent relapse.

1. Psychological Therapy

  • CBT with Exposure and Response Prevention (ERP): Gold standard; involves graded exposure to feared stimuli and prevention of the compulsive response.

  • Typically requires 13–20 weekly sessions for moderate cases.

  • Useful as monotherapy in mild-to-moderate OCD or combined with medication in moderate-to-severe cases.

2. Pharmacological Treatment

First-Line: Selective Serotonin Reuptake Inhibitors (SSRIs)

  • Fluoxetine: Start 20 mg once daily; increase gradually to 40–60 mg/day; maximum 80 mg/day.

  • Fluvoxamine: Start 50 mg at night; increase gradually to 100–300 mg/day in divided doses.

  • Sertraline: Start 50 mg/day; increase to 100–200 mg/day.

  • Paroxetine: Start 20 mg/day; increase to 40–60 mg/day.

  • Citalopram: Start 20 mg/day; increase to 40 mg/day (dose limitation due to QT prolongation risk).

  • Escitalopram: Start 10 mg/day; increase to 20 mg/day.

Second-Line: Tricyclic Antidepressant (TCA)

  • Clomipramine: Start 25 mg/day; increase by 25 mg every 4–7 days; typical dose 100–250 mg/day (maximum 250 mg/day).

  • More side effects than SSRIs (anticholinergic effects, cardiac conduction abnormalities).

3. Augmentation Strategies (for partial or non-response)

  • Antipsychotics:

    • Risperidone: 0.5–2 mg/day.

    • Aripiprazole: 5–15 mg/day.

  • Glutamate modulators: N-acetylcysteine, memantine (under specialist care).

4. Severe/Refractory OCD

  • High-dose SSRIs or clomipramine combinations.

  • Intensive CBT programs.

  • Deep brain stimulation (DBS) or neurosurgery (e.g., anterior capsulotomy) in extreme, treatment-resistant cases under specialist protocols.

Treatment Duration

  • Continue pharmacotherapy for at least 12 months after remission before considering gradual taper.

  • Many patients require long-term maintenance due to high relapse rates.

Complications

  • Significant functional impairment in work, relationships, and daily activities.

  • Secondary depression and suicidal ideation.

  • Social isolation.




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