Obsessive-Compulsive Disorder (OCD)

Background

• Obsessive-compulsive disorder is characterized by obsessions and/or compulsions that are distressing, time-consuming, or cause substantial impairment.
• Obsessions are repetitive or persistent thoughts that are intrusive, unwanted, and cause distress or anxiety.
• The most common thematic obsessions in adults include:
  • fear of contamination
  • fear of causing harm (to self or others)
  • need for order, symmetry, or being "just right"
  • fear of taboo thoughts or images.
• Harm obsessions (fears of death or illness for oneself or loved ones), contamination, sexual, or somatic obsessions, and excessive scruples or guilt are most common obsessions in children and adolescents.
• Compulsions (also called rituals) are repetitive behaviors or mental acts that are not intrinsically pleasurable and are performed in response to an obsession.
• Common compulsions include:
  • repetitive washing, cleaning
  • repetitive checking (including to see if doors are locked) or seeking assurance from others
  • reordering objects or repeating actions multiple times
  • mental acts such as checking one's memory, asking for forgiveness, excessive praying, or avoiding triggers.
• OCD has a bimodal onset:
  • childhood-onset has a reported mean age of 10 years at onset
  • adolescent or young adulthood onset has a reported mean age of onset range of 19-21 years
• The majority of patients with OCD have comorbid psychiatric conditions including anxiety, mood, impulse control, and substance use disorders.

Evaluation

• In patients with suspected OCD, assess the impact on daily functioning with 1 of the following:
  • the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) (Strong recommendation)
  • the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS)
  • patient documentation of estimated hours per day spent obsessing and performing compulsive behaviors and actively avoided items or situations.
• Diagnose OCD based on presence of obsessions and/or compulsions that cause distress or interfere with activities or functions:
  • Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria includes presence of time-consuming (> 1 hour per day) obsessions and/or compulsions that are not better explained by another mental disorder or substance use.
  • ICD-10 criteria requires obsessions and/or compulsions present on most days for ≥ 2 successive weeks.
• Assessing risk of self-harm or suicide in a patient diagnosed with OCD is recommended by the National Institute for Health and Care Excellence (NICE) and the American Psychological Association (APA) (Strong recommendation).
• Assess the potential for patients with OCD to directly or indirectly harm others.

Management

• For adults:
  • Consider exposure-and-response-prevention (form of cognitive behavioral therapy [CBT]) (Weak recommendation), a serotonin reuptake inhibitor (SRI) medication, or both (Weak recommendation), depending on patient preference, level of OCD complexity and severity, and presence of depressive symptoms. NICE recommends low-intensity CBT alone for mild impairment.
    • Schedule CBT sessions for multiple times per week during the acute phase and then monthly for 3-6 months once remission has been achieved.
    • Consider an SSRI such as fluoxetine, fluvoxamine, paroxetine, or sertraline.
    • Consider clomipramine as an alternative if not responding to an SSRI or if there has been a previous good response to clomipramine.
    • Consider combination medication plus psychotherapy for patients unresponsive to either monotherapy, those with comorbid psychiatric conditions, or those who wish to limit the duration of medication use.
  • Continue successful medication treatment for ≥ 1-2 years with a gradual tapering of the dose by 10%-25% every 1-2 months, monitoring for symptom reemergence or exacerbation.
• For children and adolescents:
  • For mild-to-moderate OCD, consider exposure-and-response-prevention CBT (Weak recommendation) or guided self-help plus support and education of caregivers for patients with mild impairment.
  • For moderate-to-severe OCD (or OCD unresponsive to initial therapy), consider CBT with a serotonin reuptake inhibitor (SRI) (Weak recommendation), such as fluoxetine, sertraline, fluvoxamine, or clomipramine at appropriate dose (Weak recommendation).
  • Combination medication plus CBT is most effective. CBT monotherapy may be more effective than monotherapy with serotonin reuptake inhibitors (SRIs) in children and adolescents.
  • Withdraw SRIs after ≥ 6 months of remission by slowly tapering the dose.
• Monitor response to therapy using 1 of the methods described in the evaluation section.
• Treatment resistance or other interfering factor or comorbid condition should be considered in:
  • Adults not responding within 13-20 weeks of weekly outpatient CBT, 3 weeks of daily CBT, or 8-12 weeks of antidepressant treatment.
  • Children or adolescents with ≥ 2 trials with SRIs plus trial of CBT who have not achieved a significant response.
• For continued treatment-resistance, APA recommends:
  • Augmenting SSRI with clomipramine, buspirone, pindolol, riluzole, or once-weekly morphine sulfate with appropriate precautions.
  • Monotherapy with d-amphetamine, tramadol, monoamine oxidase inhibitors, ondansetron, transcranial magnetic stimulation, or deep brain stimulation in some cases.