Description :
- anxiety disorder (neurosis) with manifestations of obsessions and/or compulsions
- severity-dependent impact on quality of life in social functioning, marriage and family relationships, socioeconomic status and employment
ICD-9 Codes :
- 300.3 obsessive-compulsive disorders
ICD-10 Codes :
- F42.0 predominantly obsessional thoughts or ruminations
- F42.1 predominantly compulsive acts [obsessional rituals]
- F42.2 mixed obsessional thoughts and acts
- F42.8 other obsessive-compulsive disorders
- F42.9 obsessive-compulsive disorder, unspecified
Definitions :
- obsessions are recurrent and persistent thoughts, impulses or images experienced as intrusive and inappropriate
- compulsions are feelings of being driven to perform repetitive behaviors or mental acts in response to obsession or according to rules that must be applied rigidly
Types :
- 4 predominant patterns
- contamination - washing
- doubt - checking
- intrusive obsessional thoughts - no compulsion
- obsessional slowness
Who is most affected :
Incidence/Prevalence :
- prevalence of OCD in adults
- national surveys of prevalence of OCD in adults ages 26-64 years report annual prevalences ranging from 1.1% to 1.8% and lifetime prevalences ranging from 1.9% to 2.5% in United States, Canada, Puerto Rico, Germany, Korea and New Zealand; with one outlier (Taiwan had 0.4% annual and 0.7% lifetime prevalence) (J Clin Psychiatry 1994 Mar;55 Suppl:5)
- 1-month prevalence in United Kingdom was 1% males and 1.5% females in national survey; 6-month prevalences ranged from 0.7% to 2.1% in 9 population surveys (Br J Psychiatry Suppl 1988;(35):2)
- 2.8% men and 0.7% women in Iran have OCD, based on study of 25,180 Iranian adults (BMC Psychiatry 2004 Feb 14;4:2 full-text)
- prevalence of OCD in adolescents
- cumulative incidence up to 0.165% at age 13 years in Denmark
- based on national registries with all 669,995 children born in Denmark 1990-1999
- cumulative incidence of OCD per 10,000 children at selected ages
- 0.1 at age 5 years
- 0.5-1 at age 7 years
- 2.5-3.3 at age 9 years
- 8-8.3 at age 11 years
- 16.5 at age 13 years
- Reference - Arch Pediatr Adolesc Med 2007 Feb;161(2):193
Causes :
- direct cause uncertain
- socioeconomic, behavioral, cognitive, genetic and neurobiological factors have been implicated
Possible risk factors :
- OCD in first-degree relatives associated with increased risk in meta-analysis of 5 studies, but individual studies inconsistent (Am J Psychiatry 2001 Oct;158(10):1568 full-text)
- serotonin transporter promoter gain-of-function genotypes associated with obsessive-compulsive disorder
- gain-of-function genotype about twice as common in 169 whites with OCD than in 253 ethnically matched controls
- gain-of-function genotype about 2 times overexpressed in 175 probands with OCD from parents without OCD
- Reference - Am J Hum Genet 2006 May;78(5):815
Factors not associated with increased risk :
- not related to obsessive compulsive personality disorder (OCPD)
- streptococcal infection appears to not increase risk of OCD or related symptoms
- no evidence of increased risk of worries, obsessions and compulsions in prospective study of 399 children ages 4-11 years with symptomatic group A beta-hemolytic streptococcal infections, 207 children with nonstreptococcal pharyngitis and 196 well children followed for 12 weeks (Arch Pediatr Adolesc Med 2004 Sep;158(9):848)
- streptococcal infection within 3 months or 1 year showed no statistically significant association with obsessive compulsive disorder in case-control study with 33 cases and about 130 controls ages 4-13 years (Pediatrics 2005 Jul;116(1):56)
Complications :
- obsessive-compulsive disorder (OCD) associated with increased risk for suicidal ideation and possibly suicide attempts
- cross-sectional study of 7,076 persons in the Netherlands
- 809 (11.4%) had suicidal ideation, 205 (2.9%) had suicide attempts and 61 (0.86%) had OCD
- 34 (56%) with OCD had suicidal ideation (odds ratio 10.57, adjusted odds ratio 2.12 [95% CI 0.99-4.55])
- 13 (21%) with OCD had suicide attempts (odds ratio 10.01, adjusted odds ratio 1.63 [not significant])
- longitudinal study of 4,796 persons (4,246 in analysis of suicidal ideation, 4,670 in analysis of suicide attempts)
- new-onset suicidal ideation occurred in 2% and new-onset suicide attempts occurred in 0.84%
- 17.6% persons with OCD developed suicidal ideation (odds ratio 9.63, adjusted odds ratio 6.33 [95% CI 1.11-35.96])
- 6.5% persons with OCD developed suicide attempt (odds ratio 7.99, adjusted odds ratio 1.57 [not significant])
- Reference - Arch Gen Psychiatry 2005 Nov;62(11):1249
- depression, social phobias, separation anxiety, generalized anxiety disorder, panic disorder (J Am Osteopath Assoc 2002 Feb;102(2):81 PDF)
Associated conditions :
Chief Concern (CC) :
- idea or impulse intrudes consciousness persistently
- feeling of anxious dread accompanies idea or impulse
- obsession or compulsion is ego-alien
History of Present Illness (HPI) :
- consider mental rituals as compulsions, recognized as absurd and irrational, strong desire to resist obsessions and compulsions
- common obsessions include
- contamination
- safety
- fear of committing sin
- need for order
- sexual/aggressive thoughts
- common compulsions include
- cleaning
- checking
- counting/repeating
- arranging
- touching objects
- hoarding
- seeking reassurance
- making lists
- patients usually recognize and are distressed by irrational or excessive nature of obsessions or compulsions
Social History (SH) :
- onset or exacerbation of symptoms may be related to stressful life circumstances, including pregnancy and postpartum period
Skin :
- eczematous eruptions due to excessive skin washing
- excoriations due to neurodermatitis or skin picking
HEENT :
- hair loss due to excessive hair pulling
Neuro :
- neurologic and cognitive exams often otherwise normal
Making the diagnosis :
- DSM-IV-TR criteria
- presence of obsessions and/or compulsions
- obsessions defined by the following 4 criteria:
- recurrent and persistent thoughts, impulses or images experienced at some time during the disturbance as intrusive and inappropriate and cause marked anxiety and distress
- not simply worries about real-life problems
- attempts to ignore or suppress, or neutralize with other thought or action
- the person recognizes that obsessional thoughts, impulses, or images or a product of his/her own mind (not imposed from without as in thought insertion)
- compulsions defined by the following 2 criteria:
- person feels driven to perform repetitive behaviors or mental acts in response to obsession or according to rules that must be applied rigidly
- aimed at preventing or reducing distress or preventing dreadful event; not connected in realistic way with what they are designed to neutralize or prevent or are clearly excessive
- at some point, patient recognizes obsessions or compulsions are excessive or unreasonable (this does not apply to children)
- marked distress, time-consuming (take > 1 hour/day), functional interference or social interference
- if another Axis I disorder present, the content of obsessions or compulsions not restricted to it
- disorder is not due to direct physiologic effects of a substance or a general medical condition
- specify with poor insight if, for most of the current episode, the person does not recognize that the symptoms are excessive or unreasonable
Rule out :
Imaging studies :
- some have nonspecific EEG changes
- positron emission tomography (PET) may show decreased metabolism in orbital gyrus, caudate nuclei, cingulate gyrus
Other diagnostic testing :
- Yale-Brown Obsessive Compulsive Scale (Y-BOCS)
- clinician-rated, 10 li scale designed to provide specific measure of severity of OCD symptoms regardless of type of obsessions or compulsions present
- each li rated from 0 (no symptoms) to 4 (extreme symptoms), total range 0-40 with separate subtotals for severity of obsessions and compulsions
- interrater reliability for total Y-BOCS score and each of 10 individual lis was excellent, with high degree of internal consistency among all li scores based on study of 4 rates and 40 patients with OCD at various stages of treatment (Arch Gen Psychiatry 1989 Nov;46(11):1006)
- total Y-BOCS score significantly correlated with 2 of 3 independent measures of OCD and weakly correlated with measures of depression and anxiety in patients with OCD with minimal secondary depressive symptoms, based on ratings from 3 cohorts of 81 patients with OCD; Y-BOCS scale sensitive to drug-induced changes and reductions in scores specifically reflected improvement in obsessive-compulsive disorder symptoms (Arch Gen Psychiatry 1989 Nov;46(11):1012)
- children's Y-BOCS used for childhood OCD (Psychol Assess 2003 Dec;15(4):578)
- testing sometimes done by mental health clinicians
- Rorschach - overattention to detail
- Bender-Gestalt - use of small area
- DAP - attention to head and general detailing
- insufficient evidence to support routine testing for group A streptococcus or treatment with antibiotics or immune-modifying therapies in children with neuropsychiatric symptoms; literature review concludes that PANDAS is not a proven hypothesis (Pediatrics 2004 Apr;113(4):883), editorial can be found in Pediatrics 2004 Apr;113(4):907
Prognosis :
- typically chronic course with waxing and waning of symptoms
- patients who respond to medications may experience significant improvement in symptoms but are rarely cured of illness
- most patients with OCD improve but continue to have symptoms at 40 years (level 1 [likely reliable] evidence)
- prospective study of 251 patients ages 19-52 years hospitalized with OCD
- 107 not followed due to death in 75 (including 6 suicides) and loss to follow-up in 32
- 144 patients followed for mean 47 years after onset
- outcomes at 5 years
- 12 (8.3%) patients worsened
- 38 (26.4%) patients had no change in clinical severity
- 53 (36.8%) patients improved
- 41 (28.5%) patients recovered
- outcomes at 40 years
- 11 (7.6%) patients worsened
- 13 (9%) patients had no change in clinical severity
- 51 (35.4%) patients improved
- 69 (47.9%) patients recovered
- of 41 patients who recovered at 5 years, 27 stayed recovered and 15 relapsed
- Reference - Arch Gen Psychiatry 1999 Feb;56(2):121
- streptococcal infections did NOT exacerbate symptoms in prospective follow-up of 47 children ages 7-17 years with Tourette syndrome and/or obsessive-compulsive disorder followed for mean 12.7 months (Pediatrics 2004 Jun;113(6):e578 full-text)
Treatment overview :
Counseling :
- behavior therapy effective
- exposure and response prevention (also called exposure and ritual prevention, ERP, EX/RP)
- exposure may include
- in vivo exposure - gradual, prolonged confrontation with anxiety provoking stimuli
- imagined exposure
- continue exposure until anxiety decreases (habituation)
- response prevention - abstinence from rituals as opposed to active blocking
- duration of therapy 1-3 months
- other behavior therapy techniques include aversive techniques, desensitization, flooding, paradoxical intention, satiation, thought stopping maneuvers
- exposure and response prevention (ERP) appears more effective than progressive muscle relaxation (level 2 [mid-level] evidence)
- systematic review of 52 published randomized trials of treatments of OCD using standardized diagnostic criteria in adults without active phases of other disorders
- 20 trials comparing treatments that only appeared once were excluded
- 32 trials evaluated 37 treatment comparisons
- trial quality not analyzed
- 8 trials evaluated exposure and response prevention (ERP) defined as daily sessions of deliberate exposure to anxiety-providing situations until significant habituation occurs, and strict abstinence from performing rituals
- ERP more effective than progressive muscle relaxation in 2 trials based on clinician ratings
- ERP and cognitive therapy had similar efficacy in 4 trials based on self-ratings
- ERP was not significantly more effective than single component therapy (exposure or response prevention) in 2 trials based on self-ratings
- relative efficacy appeared higher with more hours spent in therapist-guided exposure
- Reference - J Consult Clin Psychol 1997 Feb;65(1):44
- clinician-guided behavior therapy more effective than computer-guided behavior therapy which is more effective than relaxation (level 1 [likely reliable] evidence)
- 218 patients ages 15-80 years with OCD (DSM-IV criteria) in North America were randomized to 2 weeks of assessment followed by 10 weeks of 1 of 3 treatments
- behavior therapy guided by behavior therapist, 11 weekly sessions lasting at least 1 hour with self-exposure homework lasting at lest 1 hour daily
- behavior therapy guided by computer accessed by telephone plus user workbook
- systematic relaxation guided by audiotape and manual
- 49% patients were taking serotonin reuptake inhibitor
- mean baseline Yale-Brown Obsessive Compulsive Scale (YBOCS) 25, range 16-39
- 16 patients with 25% or greater reduction in YBOCS during 2-week assessment period were excluded, 19 patients who violated treatment protocol or withdrew during 2-week assessment period were excluded, 183 patients started assigned therapy, 176 patients with subsequent follow-up were analyzed by intent to treat
- outcomes at 14 weeks after treatment ended
| Outcome |
Clinician BT |
Computer BT |
Relaxation |
| Mean change in YBOCS |
8 |
5.6 |
1.7 |
| % responders on Patient Global Impressions scale |
58% |
38% |
15% |
| % responders on Clinical Global Impressions scale |
60% |
38% |
14% |
- outcomes favored clinician-guided behavior therapy over computer-guided behavior therapy (NNT 5) and over relaxation (NNT 3)
- Reference - J Clin Psychiatry 2002 Feb;63(2):138
- exposure and response therapy appears more effective than clomipramine alone or pill placebo (level 2 [mid-level] evidence)
- 122 adults with OCD (DSM-III-R or DSM-IV criteria) were randomized to exposure and ritual prevention (ERP) vs. ERP plus clomipramine vs. clomipramine alone vs. pill placebo for 12 weeks
- ERP included intensive exposure and ritual prevention for 4 weeks, then 8 weekly maintenance sessions
- clomipramine maximum dose 250 mg/day
- post hoc analyses of response and remission criteria conducted using multiple response and remission definitions
- remission rates defined as Yale-Brown Obsessive Compulsive Scale score 12 or less
- 52% for 29 patients treated with ERP (71% for 21 treatment completers)
- 58% for 31 patients treated with ERP plus clomipramine (68% for 19 treatment completers)
- 25% for 36 patients treated with clomipramine alone (30% for 27 treatment completers)
- 0 for 26 patients treated with pill placebo (0 for 20 treatment completers)
- response rates using Clinical Global Impression improvement scale
- 62% for 29 patients treated with ERP (86% for 21 treatment completers)
- 70% for 31 patients treated with ERP plus clomipramine (79% for 19 treatment completers)
- 42% for 36 patients treated with clomipramine alone (48% for 27 treatment completers)
- 8% for 26 patients treated with pill placebo (10% for 20 treatment completers)
- Reference - Am J Psychiatry 2005 Jan;162(1):151, J Clin Psychiatry 2006 Feb;67(2):269
- training family member to act as cotherapist at home associated with greater improvements than patient-based behavioral management alone in randomized trial of 30 obsessive-compulsive patients (Br J Psychiatry 1990 Jul;157:133)
- no evidence of harms reported in trials or cohort studies of behavioral therapy, case reports have described some patients with unacceptable anxiety
- predictors of poorer outcome with behavioral therapy
- initial severity
- depression
- longer duration
- poorer motivation
- dissatisfaction with therapeutic relationship
- predictors of better outcome with behavioral therapy
- early adherence to exposure homework
- employment
- living with family
- no previous treatment
- having fear of contamination
- overt ritualistic behavior
- absence of depression
- in women - co-therapist (usually related to patient) enlisted to help with treatment outside of regular treatment sessions (Acta Psychiatr Scand 1994 Jun;89(6):393)
- 75% rate of maintaining improvement at 2 years (15 of 20 patients) after inpatient in-vivo exposure therapy reported (Br J Psychiatry 1975 Oct;127:349)
- cognitive-behavioral therapy (CBT)
- may include psychoeducation, cognitive training, mapping OCD target symptoms and exposure and response therapy (EX/RP)
- therapy is more intense, involving individual or group sessions with trained therapists, homework, and monitoring procedures
- cognitive-behavioral group therapy appears highly effective compared to no therapy (level 2 [mid-level] evidence)
- 47 patients with OCD (DSM-IV criteria) randomized to 12 weekly sessions of cognitive-behavioral group therapy vs. waiting list control
- 70% treatment vs. 4% control patients had improvement (p < 0.001, NNT 2)
- Reference - Psychother Psychosom 2003 Jul/Aug;72(4):211
- cognitive-behavioral therapy appears effective in children with OCD, and more effective with addition of sertraline (level 2 [mid-level] evidence)
- 112 children aged 7-17 years with DSM-IV diagnosis of OCD and Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) score 16 or higher were randomized to cognitive behavior therapy (CBT) alone vs. sertraline alone vs. CT and sertraline vs. pill placebo for 12 weeks
- evaluator blinded to treatment assignment, 97 patients (87%) completed the study but intent-to-treat analysis done
- all 3 treatments significantly reduced CY-BOCS score compared with placebo, CBT vs. sertraline results did not significantly differ, CBT plus sertraline more effective than either monotherapy
- rate of clinical remission (CY-BOCS score 10 or less) was 3.6% with placebo, 21.4% with sertraline alone (NNT 6), 39.3% with CBT alone (NNT 3) and 53.6% with CBT plus sertraline (NNT 2)
- no evidence of treatment-emergent harm to self or others
- Reference - Pediatric OCD Treatment Study (POTS) (JAMA 2004 Oct 27;292(16):1969)
- patients in combined CBT plus sertraline group were aware that they were receiving active medication, CBT alone group did not receive pill placebo (DynaMed commentary)
- group cognitive-behavioral therapy may be effective in children with OCD (level 2 [mid-level] evidence)
- individual and group cognitive-behavioral family-based therapy each appeared more effective than 4-6 week waitlist control (level 2 [mid-level] evidence) in randomized trial in 77 children and adolescents with OCD (J Am Acad Child Adolesc Psychiatry 2004 Jan;43(1):46)
- telephone-based CBT as effective as face-to-face CBT (level 1 [likely reliable] evidence)
- based on randomized trial
- 72 patients with OCD randomized to telephone vs. face to face CBT (exposure therapy and response prevention) for 10 weekly sessions
- 68 completed intervention, 65 completed 6-month follow-up
- no significant differences in Y-BOCS at 6 months or patient satisfaction
- 77% telephone vs. 67% face to face groups had reduction in Y-BOCS score of at least 2 standard deviations
- confidence intervals did not include clinically relevant differences
- Reference - BMJ 2006 Oct 28;333(7574):883 full-text
- cognitive and/or behavioral therapy appear effective in adults with OCD (level 2 [mid-level] evidence)
- based on Cochrane review with methodologic limitations
- systematic review of 7 randomized trials of psychological treatments in 222 patients with OCD
- all trials were small
- comparing all psychological treatments vs. treatment as usual, significant reductions favoring psychological treatments found for
- OCD symptom score (p < 0.00001)
- depressive symptom score (p = 0.03)
- anxiety symptom score (p = 0.01)
- comparing cognitive-behavior therapy vs. treatment as usual
- substantial reduction in OCD symptom score favoring treatment (p < 0.00001) in 5 trials with 130 patients
- non-significant reduction in depressive symptom score favoring treatment (p = 0.06) in 5 trials with 126 patients
- non-significant reduction in anxiety symptom score (p = 0.2) in 4 trials with 96 patients
- comparing cognitive therapy vs. treatment as usual
- non-significant reduction in OCD symptom score (p = 0.1) in 2 trials with 39 patients
- no significant difference in depressive symptom score in 2 trials with 39 patients
- substantial reduction in anxiety symptom score favoring treatment (p = 0.06) in 1 trial with 20 patients
- comparing behavior therapy vs. treatment as usual
- substantial reduction in obsessive compulsive symptom score favoring treatment (p < 0.00001) in 3 trials with 72 patients
- non-significant reduction in depressive symptom score (p = 0.1) in 3 trials with 59 patients
- non-significant reduction in anxiety symptom score (p = 0.2) in 2 trials with 33 patients
- Reference - systematic review last updated 2007 Feb 2 (Cochrane Library 2007 Issue 2:CD005333)
- behavior therapy and cognitive-behavior therapy appear effective in children and adolescents with OCD (level 2 [mid-level] evidence)
- based on Cochrane review with limited evidence
- systematic review of 4 randomized or quasi-randomized trials in 222 children < 18 years old with OCD
- 2 trials suggested better post-treatment functioning and reduced risk of continuing with OCD
- best estimate for treatment efficacy is reduction of 7.5 points in CY-BOCS scale (95% CI -11.55 to -3.45 points)
- 2 trials suggested behavior therapy/CBT and medication had similar efficacy
- addition of behavior therapy/CBT to medication associated with benefit in 1 trial, with reduction of 4.55 points in CY-BOCS scale (95% CI -7.55 to -1.95 points)
- Reference - systematic review last updated 2006 Aug 22 (Cochrane Library 2006 Issue 4:CD004856)
- cognitive therapy and behavioral therapy appear to have similar efficacy over 4-16 weeks (level 2 [mid-level] evidence)
- individual psychotherapy may be very effective for some patients (level 3 [lacking direct] evidence)
- review of psychotherapy of OCD can be found in Psychiatr Clin North Am 2006 Jun;29(2):585
Medications :
- serotonin reuptake inhibitors considered first-line agents for OCD
- serotonin reuptake inhibitors include selective serotonin reuptake inhibitors, clomipramine and fluvoxamine
- see selective serotonin reuptake inhibitors (SSRIs)
- 40-60% patients with OCD respond to serotonin reuptake inhibitors (Psychiatr Serv 2003 Aug; 54(8):1111)
- FDA approved serotonin reuptake inhibitors for OCD in adults
- FDA approved serotonin reuptake inhibitors for OCD in children and adolescents
- 30-day costs of some drugs for OCD at lowest usual dose as of May 31, 2008
- selective serotonin reuptake inhibitors (SSRIs)
- citalopram (Celexa) 40 mg orally once daily $105.60, generic $75.60
- escitalopram (Lexapro) 10 mg orally once daily $90.60
- fluoxetine (Prozac) 20-60 mg orally once daily $169.80, generic $76.20 (FDA approved for OCD)
- fluvoxamine (FDA approved for OCD)
- generic 50-150 mg orally twice daily $130.20
- Luvox CR 100-300 mg orally once daily $118.60
- paroxetine hydrochloride
- Paxil 40 mg orally once daily $118.50, generic $75.00 (FDA approved for OCD)
- Paxil CR 25 mg orally once daily $113.40
- paroxetine mesylate (Pexeva) 40 mg orally once daily $150.00 (FDA approved for OCD)
- sertraline (Zoloft) 100-150 mg orally once daily $105.60 (FDA approved for OCD)
- clomipramine (Anafranil) 150-250 mg orally once daily $606.60, generic $73.20 (FDA approved for OCD)
- venlafaxine
- Effexor 75 mg orally twice daily $157.20, generic $121.20
- Effexor XR 150 mg orally once daily $137.10
- Reference - Med Lett Drugs Ther 2008 Jun 30;50(1289):50 TOC
- systematic reviews support efficacy of serotonin reuptake inhibitors over placebo (level 2 [mid-level] evidence)
- based on 5 systematic reviews of trials with methodologic limitations
- selective serotonin reuptake inhibitors (SSRIs) appear effective for short-term treatment of OCD in adults (level 2 [mid-level] evidence)
- based on Cochrane review of trials with unclear allocation concealment
- systematic review of 17 randomized and quasi-randomized trials comparing SSRIs vs. placebo in 3,097 adults with OCD
- all trials were rated as having unclear allocation concealment
- SSRIs associated with reduced symptoms on Yale-Brown Obsessive Compulsive Scale at 6-13 weeks post-treatment (weighted mean difference [WMD] -3.21) in analysis of 17 trials with 3,097 patients (p < 0.00001), results were similar between individual SSRI drugs
- clinical response at post-treatment occurred in 43.6% SSRI vs. 22.6% placebo patients in analysis of 13 trials with 2,697 patients (p < 0.00001, NNT 5), results were similar between individual SSRI drugs
- nausea, headache and insomnia most frequently reported adverse effects in trials of individual drugs
- Reference - systematic review last updated 2007 Nov 10 (Cochrane Library 2008 Issue 1:CD001765), commentary can be found in Am Fam Physician 2008 May 1;77(9):1252
- systematic review of 47 randomized double-blind comparisons (36 articles) of antidepressants for OCD for at least 4 weeks
- most trials reported completer analysis and not intent-to-treat analysis
- clomipramine and SSRIs as a class each significantly reduced obsessive-compulsive symptoms, obsessions alone and compulsions alone
- estimated increase in improvement rates over placebo for Y-BOCS were
- 61% for clomipramine (NNT 2) based on 5 trials with 607 patients
- 28.5% for fluoxetine (NNT 4) based on 1 trial with 287 patients
- 28.2% for fluvoxamine (NNT 4) base don 3 trials with 395 patients
- 21.6% for sertraline (NNT 5) based on 3 trials with 270 patients
- in direct comparisons
- Reference - Br J Psychiatry 1995 Apr;166(4):424
- consistent findings reported in subsequent systematic review
- results for each drug limited by considerable heterogeneity
- results expressed as difference in improvement (decrease) in Y-BOCS between active drug and placebo so negative numbers represent improvement
- most serotonin reuptake inhibitors had significant improvement over placebo in meta-analyses
- clomipramine -8.19 (95% CI -10.53 to -5.85) in 7 trials
- fluvoxamine -4.84 (95% CI -7.78 to -1.83) in 4 trials
- paroxetine -3 (95% CI -4.91 to -1.09) in 1 trial
- fluoxetine 20 mg -1.61 (95% CI -2.18 to -1.04) in 3 trials
- sertraline 50 mg -2.47 (95% CI -6.13 to 1.2) in 4 trials (not statistically significant)
- SSRIs combined -1.85 (95% CI -2.43 to -1.27) in 12 trials
- trazodone 0.13 (95% CI -1.34 to 1.6) in 1 trial (no difference)
- no differences in trials directly comparing clomipramine with fluvoxamine, fluoxetine or paroxetine
- Reference - J Clin Psychopharmacol 2002 Jun;22(3):309
- serotonin reuptake inhibitors associated with reduced obsessive-compulsive symptoms in children and adolescents (level 2 [mid-level] evidence)
- systematic review of 12 randomized double-blind trials of serotonin reuptake inhibitors in 1,044 children or adolescents < 19 years old with OCD
- drugs studied were fluoxetine (3 trials), paroxetine (2 trials), fluvoxamine (1 trial), sertraline (1 trial) and clomipramine (5 trials); comparators were placebo (9 trials) and desipramine (3 clomipramine trials)
- sample sizes ranged from 13 patients (crossover trial) and 16 patients (parallel trial) to 203 patients (parallel trial); 6 trials had fewer than 50 patients
- completer rates ranged from 32% to 100%, 5 or 6 trials (including most larger trials) had completer rates < 80%
- primary outcomes were change in scores and posttreatment scores
- pooled standardized effects sizes found mean difference 0.46 (95% CI 0.37-0.55), estimated difference about 4 points in Children's Yale-Brown Obsessive Compulsive Scale
- each individual drug had statistically significant effect compared to placebo
- Reference - Am J Psychiatry 2003 Nov;160(22):1919 full-text
- selective serotonin reuptake inhibitors (SSRIs) and other second generation antidepressants appear to increase response rates but may have small risk of suicidal ideation in children and adolescents (level 2 [mid-level] evidence)
- based on systematic review without sensitivity analysis limited to high-quality trials
- systematic review of 27 randomized placebo-controlled parallel trials of SSRIs, nefazodone, mirtazapine or venlafaxine in children or adolescents < 19 years old with major depressive disorder or anxiety disorders
- trials generally had good methodological quality
- obsessive-compulsive disorder (OCD) evaluated in 6 trials with 718 children and adolescents
- median duration of treatment 11 weeks
- comparing second-generation antidepressant vs. placebo in OCD
- 52% vs. 32% met study-defined measure of treatment response (p < 0.001, NNT 6, 95% CI 4-8) in 6 trials with 705 patients
- 62% vs. 40% treatment response in children < 12-13 years old (p < 0.001, NNT 5) in 4 trials with 294 children
- 49% vs. 32% treatment response in adolescents > 12-13 years old (p < 0.001, NNT 6) in 4 trials with 235 adolescents
- 1% vs. 0.3% suicidal ideation or suicide attempt (not significant)
- Reference - JAMA 2007 Apr 18;297(15):1683, commentary can be found in JAMA 2007 Aug 8;298(6):626
- subsequent randomized trials found efficacy over placebo for
- comparative efficacy of serotonin reuptake inhibitors
- no significant differences in efficacy in 2 systematic reviews and 4 subsequent randomized trials
- sertraline improved reduction in Yale-Brown Obsessive Compulsive Scale score by 8% compared to clomipramine in 1 randomized trial with 170 patients (Eur Psychiatry 1997;12:82)
- adverse effects
- serotonin reuptake inhibitors may improve symptoms compared with tricyclic antidepressants or monoamine oxidase inhibitors (level 2 [mid-level] evidence), based on
- predictors of poor response to serotonin reuptake inhibitors
- younger age of onset
- longer duration
- higher frequency of symptoms
- coexisting personality disorder
- tic disorder
- predictors of good response to serotonin reuptake inhibitors
- older age of onset
- history of remissions
- no previous drug treatment
- more severe OCD
- addition of serotonin reuptake inhibitors to behavioral or cognitive therapy not adequately studied
- addition of fluvoxamine (maximum dose 300 mg/day, mean dose 288 mg/day) to multimodal behavior therapy associated with higher response rate (87.5% vs. 60%, NNT 4) in 9-week randomized placebo-controlled trial in 60 patients (Br J Psychiatry Suppl 1998;35:71)
- no significant differences found comparing cognitive therapy for 16 weeks, exposure in vivo with response prevention for 16 weeks, fluvoxamine for 16 weeks plus cognitive therapy in latter 8 weeks, and flluvoxamine for 16 weeks plus exposure therapy in latter 8 weeks in randomized trial with 117 patients and 26.5% dropout rate; all 4 treatments were more effective than waiting list control for 8 weeks (J Nerv Ment Dis 1998 Aug;186(8):492)
- venlafaxine appears as effective as serotonin reuptake inhibitors, based on
- treatment of patients who fail to respond to adequate trial of serotonin reuptake inhibitor
- only about 25% of patients who fail to respond to one SRI will respond to a second SRI trial (Journal of Clinical Psychiatry 1997;58(suppl 5):32)
- addition of antipsychotics to SSRI for refractory OCD has inconsistent results in small trials
- antipsychotic augmentation might be beneficial in patients with OCD refractory to SSRI (level 2 [mid-level] evidence)
- based on Cochrane review
- systematic review of 28 short-term randomized trials of pharmacotherapy augmentation in 740 patients with treatment-resistant anxiety disorders
- 20 trials evaluated treatment-resistant OCD
- comparing treatment vs. control in OCD patients
- 32% vs. 14% response in Clinical Global Impression of Improvement (p = 0.04, NNT 6) in meta-analysis of 9 trials with 250 patients, but meta-analysis limited by heterogeneity
- 38% vs. 17% response (p = 0.05, NNT 5) in meta-analysis of 6 trials of antipsychotics in 187 patients, but limited by heterogeneity
- Reference - systematic review last updated 2006 Aug 22 (Cochrane Library 2006 Issue 4:CD005473)
- AHRQ evidence review of benefits and harms of atypical antipsychotics in obsessive-compulsive disorder
- potential benefits
- 12 trials of risperidone, olanzapine and quetiapine used as augmentation therapy in patients with OCD resistant to standard treatment were found
- 9 trials provided evidence of clinically important benefit in patients who failed serotonin reuptake inhibitor therapy
- risperidone and quetiapine had moderate evidence
- olanzapine had sparse evidence and inconsistent results
- no trials found for ziprasidone or aripiprazole
- potential harms
- atypical antipsychotics associated with small but significant increased mortality in placebo-controlled trials in dementia patients
- risperidone and olanzapine associated with small but significant increased risk for stroke in placebo-controlled trials in dementia patients
- risperidone, olanzapine and aripiprazole associated with increased risk for neurological side effects (fatigue, headaches, dizziness) in placebo-controlled trials
- insufficient evidence comparing atypical antipsychotics with each other or other active controls for the above outcomes, insufficient evidence regarding other cardiovascular side effects
- extrapyramidal symptoms
- sedation more common with atypical antipsychotics than placebo, and more common with olanzapine than mood stabilizers
- weight gain more common with olanzapine than placebo, conventional antipsychotics and other atypical antipsychotics; weight gain more common with risperidone than placebo
- Reference - AHRQ Effective Health Care report 2007 Jan 17:6 PDF
- 3 small trials suggest benefit
- 2 small trials suggest no benefit
- addition of D-cycloserine to exposure therapy has conflicting evidence
- based on 2 trials
- no benefit in randomized placebo-controlled trial
- 24 adults with obsessive compulsive disorder randomized to D-cycloserine 250 mg vs. placebo taken 4 hours prior to each session of exposure and response prevention therapy
- all patients received 12 weekly sessions of exposure and response prevention therapy
- no significant difference in rate of improvement between groups
- Reference - Int Clin Psychopharmacol 2007 Jul;22(4):230
- more rapid recovery in double-blinded trial
- patients having extinction-based exposure therapy for OCD were treated with D-cycloserine 125 mg vs. placebo about 2 hours prior to each exposure session
- D-cycloserine reduced number of exposure sessions required to reach clinical milestones and rate of therapy dropout
- patients in D-cycloserine group reported significantly greater reductions in obsession-related distress compared to placebo group after 4 sessions
- no significant differences between groups after additional sessions
- Reference -Biol Psychiatry 2007 Oct 15;62(8):835
- plasma exchange and IVIG may be effective in reducing symptom severity for children with infection-triggered OCD and tic disorders; 30 children with severe, infection-triggered exacerbations of obsessive-compulsive disorder or tic disorders randomized to plasma exchange (5 single-volume exchanges over 2 weeks) vs. IVIG (1 g/kg once daily on 2 consecutive days) vs. placebo (saline IV once daily on 2 consecutive days); symptoms reported as reduced in plasma exchange and IVIG groups significantly more than in placebo group (Lancet 1999 Oct 2;354(9185):1153), editorial not recommending this treatment with multiple criticisms can be found in Lancet 1999 Oct 2;354(9185):1137
- Saint John's wort 600-1,800 mg/day no more effective than placebo (level 2 [mid-level] evidence) in randomized trial with 60 patients with obsessive compulsive disorder (conference abstract in Altern Ther Health Med 2006 May-Jun;12(3):54)
Surgery :
- cingulotomy for intractable cases has been described in case series (level 3 [lacking direct] evidence)
- 32% complete response and 45% partial response reported at mean 32 months after 1 or more cingulotomies in series of 26 patients with treatment-refractory OCD (Am J Psychiatry 2002 Feb;159(2):269)
- in series of 15 patients with OCD treated with radiofrequency cingulotomy, only 4 had decrease of more than 35% on Y-BOCS scale and only 1 had sustained benefit for more than 1 year (Neurosurgery 2004 Mar;54(3):622)
- anterior cingulotomy reported to provide response (at least 35% reduction in Y-BOCS scores and very much or much better on Clinical Global Impression) at 1 year in 6 of 14 patients with severe refractory OCD (Acta Psychiatr Scand 2003 Apr;107(4):283)
Other management :
Follow-up :
Screening :
- inquire about intrusive thoughts, rituals or tics; be sensitive to patients’ awareness that these may seem unusual or irrational
- look for physical signs
- listen for repeated requests for testing without clinical indications
- screen for psychiatric comorbidities
- potential screening tools
- Yale-Brown Obsessive Compulsive Scale (Y-BOCS)
- Quick PsychoDiagnostics (QPD) Panel is an automated screening test using hand-held devices that patients can use in physician's office which provides easily understandable printout of scores upon screening for depression, anxiety, panic disorder, obsessive-compulsive disorder, bulimia, alcohol/substance abuse and somatization; QPD Panel had 69% sensitivity and 97% specificity for DSM-IV obsessive-compulsive disorder in study of 203 HMO patients referred for first-time mental health consultation, 8% prevalence (J Fam Pract 2000 Jul;49(7):614)
- obsessive-compulsive disorder subscale (OCS) created from Child Behavior Checklist (CBCL) and had high positive and negative predictive values in study of 219 children and adolescents (Pediatrics 2001 Jul;108(1):e14 full-text)
General references used :
- Clinical Evidence 2006 (search date 2004 May)
Reviews :
Guidelines :
Patient information :
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