Obsessive-Compulsive Disorder: Diagnosis and Management

 

Obsessive-compulsive disorder (OCD) is a chronic illness that can cause marked distress and disability. It is a complex disorder with a variety of manifestations and symptom dimensions, some of which are underrecognized. Early recognition and treatment with OCD-specific therapies may improve outcomes, but there is often a delay in diagnosis. Patients can experience significant improvement with treatment, and some may achieve remission. Recommended first-line therapies are cognitive behavior therapy, specifically exposure and response prevention, and/or a selective serotonin reuptake inhibitor (SSRI). Patients with OCD require higher SSRI dosages than for other indications, and the treatment response time is typically longer. When effective, long-term treatment with an SSRI is a reasonable option to prevent relapse. Patients with severe symptoms or lack of response to first-line therapies should be referred to a psychiatrist. There are a variety of options for treatment-resistant OCD, including clomipramine or augmenting an SSRI with an atypical antipsychotic. Patients with OCD should be closely monitored for psychiatric comorbidities and suicidal ideation.

Obsessive-compulsive disorder (OCD) is a neuropsychiatric disorder characterized by recurrent distressing thoughts and repetitive behaviors or mental rituals performed to reduce anxiety. Symptoms are often accompanied by feelings of shame and secrecy. In addition, health care professionals do not always recognize the diverse manifestations of OCD. These factors often lead to a long delay in diagnosis. The average time it takes to receive treatment after meeting diagnostic criteria for OCD is 11 years.1 Primary care physicians can play a crucial role in reducing the burden of OCD through early detection and treatment.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Patients with OCD should be monitored for psychiatric comorbidities and suicide risk.

C

1517

Cognitive behavior therapy, specifically exposure and response prevention, is the most effective psychotherapy method for treating OCD.

A

17, 20, 21

SSRIs are recommended as first-line pharmacologic therapy for OCD.

A

17, 21, 29

A trial of SSRI therapy should continue for 8 to 12 weeks, with at least 4 to 6 weeks at the maximal tolerable dosage.

C

17

Indefinite SSRI therapy should be considered to prevent OCD relapse. At a minimum, SSRIs should be continued for 1 to 2 years before attempting to discontinue.

C

17, 22

Augmenting SSRI therapy with an atypical antipsychotic is effective in some patients with OCD who have inadequate response to SSRI therapy.

B

17, 25, 37


OCD = obsessive-compulsive disorder; SSRI = selective serotonin reuptake inhibitor.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Patients with OCD should be monitored for psychiatric comorbidities and suicide risk.

C

1517

Cognitive behavior therapy, specifically exposure and response prevention, is the most effective psychotherapy method for treating OCD.

A

17, 20, 21

SSRIs are recommended as first-line pharmacologic therapy for OCD.

A

17, 21, 29

A trial of SSRI therapy should continue for 8 to 12 weeks, with at least 4 to 6 weeks at the maximal tolerable dosage.

C

17

Indefinite SSRI therapy should be considered to prevent OCD relapse. At a minimum, SSRIs should be continued for 1 to 2 years before attempting to discontinue.

C

17, 22

Augmenting SSRI therapy with an atypical antipsychotic is effective in some patients with OCD who have inadequate response to SSRI therapy.

B

17, 25, 37


OCD = obsessive-compulsive disorder; SSRI = selective serotonin reuptake inhibitor.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

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WHAT IS NEW ON THIS TOPIC: OCD

In the Diagnostic and Statistical Manual of Mental Disorders, 5th ed., OCD is recognized as a disorder distinct from anxiety.

Incorporating motivational interviewing may increase engagement with cognitive behavior therapy for OCD and improve its effectiveness.


OCD = obsessive-compulsive disorder.

WHAT IS NEW ON THIS TOPIC: OCD

In the Diagnostic and Statistical Manual of Mental Disorders, 5th ed., OCD is recognized as a disorder distinct from anxiety.

Incorporating motivational interviewing may increase engagement with cognitive behavior therapy for OCD and improve its effectiveness.


OCD = obsessive-compulsive disorder.

Epidemiology

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The Authors

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JILL N. FENSKE, MD, is a clinical assistant professor in the Department of Family Medicine at the University of Michigan Medical School, Ann Arbor....

KETTI PETERSEN, MD, is a clinical lecturer in the Department of Family Medicine at the University of Michigan Medical School.

Author disclosure: No relevant financial affiliations.

Address correspondence to Jill N. Fenske, MD, Dept. of Family Medicine, University of Michigan, 1150 W. Medical Center Dr., M7300 Med Sci I, SPC 5625, Ann Arbor, MI 48109-5625 (e-mail: jnfenske@med.umich.edu). Reprints are not available from the authors.

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