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.
|Treatment||Initial daily dosage||Target daily dosage||Common side effects|
|Selective serotonin reuptake inhibitors*||Anxiety, decreased libido, sexual dysfunction, diarrhea, sedation, headache, insomnia, dizziness, nausea|
|Fluoxetine||20 mg||80 mg|
|Fluvoxamine||50 mg||300 mg|
|Sertraline||50 mg||200 mg|
|Paroxetine||20 mg||60 mg|
|Citalopram||20 mg||60 mg|
|Clomipramine||25 to 50 mg||250 mg||Dizziness, sedation, dry mouth, weight gain, sexual dysfunction|
|Venlafaxine||75 mg||375 mg||Accommodation disorder, blurred vision, headache, sexual dysfunction, paresthesias, nausea, weight loss, withdrawal syndrome (dizziness, nausea, weakness)|
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.