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Obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a psychiatric disorder, specifically, an anxiety disorder. OCD is manifested in a variety of forms, but is most commonly characterized by a subject's obsessive drive to perform a particular task or set of tasks, compulsions commonly termed rituals. more...

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OCD should also be distinguished from the similarly named but notably different obsessive-compulsive personality disorder, which psychiatric guidelines define as a personality characteristic rather than an anxiety disorder.

The phrase "obsessive-compulsive" has worked its way into the wider English lexicon, and is often used in an offhand sense to describe someone who is meticulous or absorbed in a cause. Such casual references should not be confused with obsessive-compulsive disorder; see clinomorphism. It is also important to distinguish OCD from other types of anxiety, including the routine tension and stress that appear throughout life. A person who shows signs of infatuation or fixation with a subject/object, or displays traits such as perfectionism, is not necessarily stricken with OCD, a specific and well-defined disorder.

Symptoms and prevalence

Modern research has revealed that OCD is much more common than previously thought. An estimated two to three percent of the population of the United States is thought to have OCD or display OCD-like symptoms. Because of the condition's personal nature, and the lingering stigma that surrounds it, there may be many unaccounted-for OCD sufferers, and the actual percentages could be even higher.

The typical OCD sufferer performs tasks (or compulsions) to seek relief from obsessions. To others, these tasks may appear simple and unnecessary. But for the sufferer, such tasks can feel critically important, and must be performed in particular ways for fear of dire consequences and to stop the stress build up. Examples of these tasks: repeatedly checking that one's parked car has been locked before leaving it; turning lights on and off a set number of times before exiting a room; repeatedly washing hands at regular intervals throughout the day.

OCD rituals are often bound up with intricate detail — detail that may seem arbitrary to outsiders. Smokers with OCD, for instance, may argue with themselves that quitting cigarettes is possible only on the 13th or 27th of a month, and only when they are in possession of four cigarettes at noon.

Obsessions are thoughts and ideas that the sufferer cannot stop thinking about. Common OCD obsessions include fears of acquiring disease, getting hurt, or causing harm to someone. Obsessions are typically automatic, frequent, distressing, and difficult to control or put an end to by themselves. People with OCD who obsess over hurting themselves or others are actually less likely to do so than the average person.

Compulsions refer to actions that the person performs, usually repeatedly, in an attempt to make the obsession go away. For an OCD sufferer who obsesses about germs or contamination, for example, these compulsions often involve repeated cleansing or meticulous avoidance of trash and mess. Most of the time the actions become so regular that it is not a noticeable problem. Common compulsions include excessive washing and cleaning; checking; hoarding; repetitive actions such as touching, counting, arranging and ordering; and other ritualistic behaviors that the person feels will lessen the chances of provoking an obsession. Compulsions can be observable — washing, for instance — but they can also be mental rituals such as repeating words or phrases, or counting.

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Management strategies for obsessive-compulsive disorder
From American Family Physician, 10/1/04 by Bill Zepf

Patients with obsessive-compulsive disorder (OCD) often seek care from physicians other than psychiatrists. Jenike reviewed the diagnosis and treatment of this disorder, which affects 2 to 3 percent of persons worldwide.

OCD typically appears during the young adult years and has a chronic waxing and waning course. Although treatment can lessen the severity of the disorder, patients typically have some residual symptoms. Because both patients and physicians may be unfamiliar with the symptom complex that denotes OCD, it often is many years before affected patients are properly diagnosed and treated.

OCD appears to have a genetic basis. The concordance rate for the diagnosis in monozygotic twins is more than 80 percent. Although some neurologic findings have been associated with OCD, such as increased gray matter and decreased white matter on brain imaging, the diagnosis remains a clinical one.

Patients with OCD are distressed by recurrent obsessions and often perform compulsive washing and checking rituals in an attempt to deal with the anxiety provoked by their obsessions. Those affected by OCD usually recognize that their behavior is irrational and may spend a lot of effort to hide their symptoms from others. Since patients rarely present voluntarily for treatment, three quick screening questions can be used during an office visit if OCD is suspected: "Do you have repetitive thoughts that make you anxious and that you cannot get rid of regardless of how hard you try?"; "Do you keep things extremely clean and tidy or wash your hands frequently?"; and "Do you check things to excess?"

Cognitive behavior therapy usually is employed in the treatment of OCD. Patients are asked to list all of their obsessions and rank them in order of the severity of the anxiety they provoke. In a supportive environment, the therapist then exposes the patient to an obsession that causes a medium level of anxiety. Exposures are repeated until the patient no longer feels anxious. With each success, the therapist helps the patient move up to other obsessions that cause greater anxiety. Exposure sessions of at least 90 minutes have been shown to be superior to shorter therapy episodes, and up to 20 sessions may be needed to provide meaningful relief of symptoms.

In most patients, combining medication with behavioral therapy produces the best results. See the accompanying table for a list of medications commonly used for OCD. Selective serotonin reuptake inhibitors (SSRIs) generally are employed first, with other psychotropic agents added if initial therapy fails. The optimal SSRI dosage for OCD tends to be higher than the dosage used to treat depression, and an adequate trial of medication may take up to 12 weeks.

Of the other medications that are used for treating OCD, the most data have been accumulated for combinations of low dosages of dopamine antagonists used with SSRIs. In severe cases of OCD, a number of neurosurgical procedures have been described, and deep brain stimulating electrodes have been used, but the author cautions that no studies have directly compared the relative efficacy or safety of these invasive treatments.

Jenike MA. Obsessive-compulsive disorder. N Engl J Med January 15, 2004;350:259-65.

COPYRIGHT 2004 American Academy of Family Physicians
COPYRIGHT 2004 Gale Group

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