By-Dr. abid rizvi
Jr2 department of psychiatry
a common and disabling disorder marked
by obsession, compulsion or both.
Prevalence is around 2% world wide
Up to 1980 considered a treatment resistant chronic
condition of psychological origin.
The observation that CLOMOPRAMINE
(a TCA with serotogenic profile) is effective was a major
Prehistoric times-possessed by devil and exorcism as
During Renaissance(16 to 14 century ) devil theory was
replaced by other naturalistic (albeit contradictory )
Oxford Don, Robert Burton, reported a case, the Anatomy
of Melancholy (1621): "If he be in a silent auditory, as at a
sermon, he is afraid he shall speak aloud and
unaware, something indecent, unfit to be said”(religious
In 1660, Jeremy Taylor,, was referring to obsessional
doubting when he wrote of "scruples": [A scruple] is
trouble where the trouble is over, a doubt when doubts
Different theories led to different treatment
Laxative and purgatives.
Henry Maudsley (1895) - opium and morphine, to be
taken three times a day,
adding low doses of arsenic along with these narcotics
could be helpful.
During 18 and 19 century - growth of mental asylum.
J.E.D. Esquirol advocated that such patients shouldn’t be
placed in mental asylums. he described OCD as a form of
Late 19th century, consensus was that OCD was not a
form of insanity.
More unusual to put OCD sufferers in asylums
Westpahal ascribed obsessions to disordered intellectual
function. He use of the term Zwangsvorstellung
In Great Britain Zwangsvorstellung was translated as
"obsession," while in the United States it become
The term “OCD" emerged as a compromise.
(Freud‘) patient's mind responded mal adaptively to
conflicts between unacceptable, unconscious sexual or
aggressive id and the demands of conscience and reality.
It regressed to concerns with control and to modes of
thinking characteristic of the anal-sadistic stage of :
AMBIVALENCE, which produced doubting,
MAGICAL THINKING ,superstitious compulsive acts.
Ego marshalled certain defenses:
INTELLECTUALIZATION AND ISOLATION
The imperfect success of these defenses gave rise to ocd
symptoms: (anxiety; preoccupation with dirt or germs or
moral questions; and, fears of acting on unacceptable
Lifetime prevalence is 2% to 3%
Equal across sex and culture.
Prevalence among adult and children same
67% have MADD ,25% have social phobias.
25% chronic schizophrenic have OCD symptoms.(poor
? Schizo-obsessive category
Other co-morbid- panic disorder ,eating disorder ,alcohol
Relationship with OCPD is debatable.(OCPD ) is not a
prominent risk factor for developing OCD.
CLINICAL FEATURE AND
Characterized by obsession, compulsion or both(75%)
Obsessional thoughts are- ideas, images or impulses that enter
the individual's mind again & again in a stereotyped form.
Are invariably distressing ( they are violent or obscene, or
simply because they are perceived as senseless) .
The sufferer often tries, unsuccessfully, to resist them.
Are, recognized as the individual's own thoughts, even though
they are involuntary and often repugnant.
Compulsive acts are stereotyped behaviors that are repeated again
Are not inherently enjoyable, nor do they result in the completion of
inherently useful tasks.
Individual often views them as preventing some objectively unlikely
event ,often involving harm to or caused by himself or herself.
Usually, this behaviour is recognized by the individual as pointless
or ineffectual and repeated attempts are made to resist it;( in very
long-standing cases, resistance may be minimal).
DSM 4 criteria of obsession
1. Recurrent and persistent thoughts, impulses, or images
that are experienced at some time during the disturbance
as intrusive and inappropriate and that cause marked
anxiety or distress .
2. The thoughts, impulses, or images are not simply
excessive worries about real-life problems
3. The person attempts to ignore or suppress such
thoughts, impulses, or images, or to neutralize them with
some other thought or action
4. The person recognizes that the obsessional
thoughts, impulses, or images are a product of his or her
own mind (not imposed from without as in thought
Compulsions are defined by (1) and (2)
1. Repetitive behaviors or mental acts that the person feels
driven to perform in response to an obsession, or
according to rules that must be applied rigidly
2. The behaviors or mental acts are aimed
at preventing or reducing distress or
preventing some dreaded event or situation;
however, these behaviors or mental acts either are not
connected in a realistic way with what they are designed
to neutralize or prevent or are clearly excessive
Sims textbook of psychopathology states that:
“Certainly OCD is not an anxiety disorder. Isolated
obsession or obsessive compulsive disorder may occur
with or without anxiety, with or without depression and
with or without personality disorder .It is a distinct and
The three essential feature of OCD are:
1.A feeling of subjective compulsion
2a resistance to it
3.Preservation of insight
The sufferer knows that it his own thought (or act) ; arises
from within himself and that it is subject to his own will.
whether he continues to think(or perform).
.He is tormented by the fear of what may happen if he
disturbs the routine.
The person usually functions satisfactorilly in other areas
of his life untouched by his obsession thout, but as the
obsession becomes more severe there is in creasing social
incapability and mystery that can grossy impair his life.
This is also reflected in thee icd 10 classification which
lists ocd as a saperate entity from anxiety disorder.
repugnant to the individual. prudish person is tormented
by sexual thoughts, the religious person by blasphemous
thoughts, and the timid person by thoughts of
torture, murder and general mayhem.
obsessional symptoms or compulsive acts, or both, must be present
on most days for at least 2 successive weeks and be a source of
distress or interference with activities.
(a)they must be recognized as the individual's own thoughts or
(b)there must be at least one thought or act that is still resisted
unsuccessfully, even though others
may be present which the sufferer no longer resists;
(c)the thought of carrying out the act must not in itself be
pleasurable (simple relief of tension or
anxiety is not regarded as pleasure in this sense);
(d)the thoughts, images, or impulses must be unpleasantly
Predominantly obsessional thoughts or ruminations
These may take the form of ideas, mental images, or impulses
to act. They are very variable in content but nearly always
distressing to the individual.
Sometimes the ideas are merely futile, involving an endless
and quasi-philosophical consideration of imponderable
This indecisive consideration of alternatives is an important
element in many other obsessional ruminations and is often
associated with an inability tomake trivial but necessary
decisions in day-to-day living.
Predominantly compulsive acts [obsessional rituals]
The majority of compulsive acts are concerned with cleaning
(particularly hand-washing), repeated checking to ensure that
a potentially dangerous situation has not been allowed to
develop, ororderliness and tidiness.
Underlying the overt behaviour is a fear, usually of danger
or caused by the patient, and the ritual act is an ineffectual or
symbolic attempt to avert that danger.
Compulsive ritual acts may occupy many hours every day and
are sometimes associated with marked indecisiveness and
Mixed obsessional thoughts and acts
Most obsessive-compulsive individuals have elements of
both obsessional thinking and compulsive behaviour. This
subcategory should be used if the two are equally
prominent, as is often the case, but it is useful to specify
only one if it is clearly predominant, since thoughts and
acts may respond to different treatments.
The essential feature of obsession is that it occurs against
the patient’s will
Hence only that event is obsession which under normal
circumstances can be controled and resisted
OBSESSION CAN BE
Are derivative of in tolerable or forbidden impulse
May be simple (repeatition of simple words or tunees) or
Rumination: these are pseudophilosophical ,irritating
unnecessary ,repititive and achieve
no conclusion.(why the sky is blue
Eg of obsessive impulses are
impulse to touch ,count or arrange objects
Commit antisocial acts .(mother harming her baby
and priest of abusing in public).
Rarely carry out impulse.(reassurance can given provided
that it is truly obsessional and not accompanied by
depression and antisocial personality disorder).
these are very vivid images(gravestones with names )
Can be mistaken for hallucination(but are the product of
patient’s own mind)
Are one of the 4 types
1. Obsessive images: Images of flowing blood, Injuries
and so on.
2. Compulsive image: A woman who saw the coffin of
her child had to image her child standing happily.
3. Disaster images:
Compulsive checker see the actual
disaster happening if they do not check.
4. Disruptive image :
May disrupt the ritual being
performed and the whole ritual has to be repeated
Fear: groundless fear which the patient realises as
dominating without cause.
1. Most comman .
2. Obsession of contamination –repeated
washing-compulsive avoidance of presumed
3. rub off their skin unable to leave their home
due to fear of germs.
It is interesting how the obsessional person omits other
areas from his obsessionlity.
(The patient who excoriates his hand by excessive
washing and devotes a substantial portion of each day to
the pursuits of cleaniness may drive to work in a dirty and
ill serviced car and work in an untidy office).
The delimma of obsessional symptoms remain that they
are both reckoned as part of the patient’s own behavior
and resisted un succesfully that is they are under
voluntary control but not all experienced as voluntary.
Second most comman
Obsession of doubt –compulsion of checking.
Only intrusive thought without compulsive act(sexual or
May take hours to do simple act as to shave or to cook a
Major presenting symptoms
Concern with body waste,dit germs,toxins
Fear of terrible happening
Symmetry,order ,or exactness
Exceesive religious concern or praying(srupulocity)
Lucky and unlucky numbers
Forbidden or perversed sexual thought ,images ,impulses
Intrusive non sense sounds words or music
Exessive or ritualised handwashing , bathing toothbrushing, grooming
Repeated rituals(going in & out of door , up & do2wn from chair)
Cheking doors lock stove car breaks
Othering & arranging
Measure t prevent harm to self or others
Miscellaneous rituals (liking , spiting, specila dress pattern)
1. Dysregulation of sserotogenic system
2. ?pathogeenesis involvement.
Measurng the level of 5HIAA( ammeeasure of serotonic
turnn over) in CSF
Affinities of platelet serotonin bindind sites to
No consistent result found
Some study - decreased level of 5HIAA AFTER
TREATMENT WITH CLOMIPRAMINE and normalization of
plaatelet transporter after treatment with clomipramine.
1. ABUDANCE OF ocd symptom in basal ganglia disorer
such as tourette syndrome ,postencephalitic
parkinsonism ,and synderham’s chorea.
2. Also the efficacy of dopamine blocker and sri in
ccontrolling the obsessive symptoms in subsects.
all above evidence supports the
REDUCED SEROTONIN ACTIVITY AND INCREASED
DOPAMINE TRANSMISSION IN OCD.
10 TO 30% OF PATIENT of reumatic fever develop
synderham’s chorea and showw symptoms of OCD.
CELL mediated immune function dysfunction have been
reported in OCD but has not been replicated in other
Realtives of proband with OCD have 3 to 4 times higher
rates of the disorder.
Monozygote twins have higher concordence rate as
compared to dgygote twins.
Increased rate of variety of condition in patients of OCD
proband ( eating disorder, body dysmorphic
disorder,hypochondriasis, tics disorder).
BRAIN IMAGING STUDIES.:
PET scan has shown increased activity in the frontal lobe,
caudate nucleus, and the cingulum of patients.
CT AND MRI have shown decreased size of caudate nucleus
DYSREGULATION OF FRONTAL Caudate thalamus
Pharmacological and behavioral therapy reverse these
obsession are conditioned stimuli
A relatively neutral stimuli become associated with fear or
anxety through classical conditioning.previouslyy neutral
stimuli become anxiety provocing.
When a patient learns thaat a certain behavior reduces
anxiety it become fixed to thee behavior via learning of
TREATING OBSESSIVECOMPULSIVE DISORDER
1. Establish and maintain a therapeutic alliance.
Tailor communication style to the patient needs .
Allow patients with excessive worry or doubting time to
consider treatment decisions. Repeat explanations .
Attend to transference and countertransference.
Consider how the patient’€™ expectations are affected by his
or her cultural and religious background,beliefs about the
illness, and experience with past treatments.
Assess the patient’s symptoms.
Use DSM-IV-TR criteria for diagnosis.
Consider using screening questions to detect commonly
Obsessive-Compulsive Disorder Screening Questions
Do you have unpleasant thoughts you cannot get rid of?
Do you worry that you might impulsively harm someone?
Do you have to count things, wash your hands, or check things?
Do you worry a lot about whether you performed religious rituals
correctly or have been immoral?
Do you have troubling thoughts about sexual matters?
Do you need things arranged symmetrically or in a very exact order?
Do you have trouble discarding things, so that your house is quite
Do these worries and behaviors interfere with your functioning at
work, with your family, or with social activities?
Differentiate OCD obsessions, compulsions, and rituals
from similar symptoms found in other disorders
How the Symptom Differs From
Symptoms of OCD
Recurrent,intrusive preoccupation The preoccupation is limited to the
with a perceived bodily defect
depressive ruminations are
experienced as consistent with
oneâ€™s self-image usually
guilt, regret, or pessimism about
the future &do not lead to
Intrusive thoughts regarding
thoughts and behaviors are
limited to weight and eating.
Unlike with OCD, worry does not
lead to compulsive rituals.
In OCD, such fear arises from an
external stimuli (e.g., that causes
Fear or belief regarding serious
contamination) rather than
misinterpretation of an ordinary
bodily sign or symptom.
Intrusive sexual thoughts and
OCD obsessions are resisted,
morally abhorrent,are avoided.
OCD thoughts and urges do not
personality disorder (OCPD)
Posttraumatic stress disorder
with rules and order
In OCD, obsessions and
compulsions usually focus on
specific feared events; in OCPD,
thoughts and behaviors are
globally colored perfectionism
and preoccupation with rules.
Intrusive thoughts and images
The thoughts replay actual
events rather than anticipate
future events as in OCD.
Complex vocal or motor tics
Tics, unlike compulsions, are
not preceded by thoughts nor
aimed at relieving anxiety or
preventing or undoing an event.
CONSIDER RATING THE PATIENT’S SYMPTOM SEVERITY
AND LEVEL OF FUNCTIONING.
Recording baseline severity provides a way to measure
response to treatment.
A useful symptom scale is (Y-BOCS),
Patient Health Questionnaire (PHQ-9), Beck Depression
Sheehan Disability Scale (SDS).
Enhance the safety of the patient and others.
Assess for risk of suicide, self-injurious behavior, and harm to
factors associated with increased risk of suicide, including
specific psychiatric symptoms and disordersr) and previous
Evaluate the patient’s potential for harming others, either
directly or indirectly (e.g., when OCD symptoms interfere with
Complete the psychiatric assessment.
Assess for common co-occuring disorders, including mood
disorders, other anxiety disorders, eating
disorders, substance use disorders, and personality
Establish goals for treatment.
include decreasing symptom frequency and
severity, improving the patient's functioning, helping the
patient to improve his or her quality of life.
targets include less than 1 h /day obsessing & compulsive
behaviors , mild OCD-related anxiety, ability to live with OCDassociated uncertainty, and little or no interference of OCD
with the tasks of daily living.
(Despite best efforts, some patients will be unable to reach
Establish the appropriate setting for treatment.
In general, patients should be cared for in the least restrictive
setting that is likely to be safe and to allow for effective treatment.
Outpatient t/t usually sufficient. More intensive settings
(e.g., hospitalization, residential treatment, or partial
patients with significant suicide risk, danger
to others, unable to provide adequate self-care, have co-occurring
psychiatric and general medical conditions, or need intensive
treatment or monitoring.
Home-based treatment may be needed by patients who are unable
to visit an office or clinic because of impairing fears or other
Enhance treatment adherence.
Recognize that the patient’™s fears, doubting, and need for certainty can influence
his or her willingness and ability to cooperate with treatment and can challenge the
Provide education about the illness and its treatment, including
outcomes and time and effort required.
Inform the patient about likely side effects of medications.
Consider the role of the patient’s family and social support system.
When possible, help the patient to address practical issues such as treatment
cost, insurance coverage, and transportation.
B. Choice of Initial Treatment
First-line treatments for OCD are cognitive-behavioral
therapy (CBT) and serotonin reuptake inhibitors (SRIs).
SRIs include clomipramine and all of the selective
serotonin reuptake inhibitors (SSRIs). Clomipramine,
fluoxetine, fluvoxamine, paroxetine, and sertraline are
approved by FDA.
controlled trials, supports using CBT that relies ON (ERP).
CBT alone is recommended for a patient who is not too depressed, anxious, or
severely ill to cooperate with this treatment modality, or who prefers not to take
In ERP, patients are taught to confront feared situations and objects (i.e., exposure)
and to refrain from performing rituals (i.e., response prevention). The goal is to
weaken the connections between feared stimuli and distress and between carrying
out rituals and relief from distress.
Cognitive techniques such as identifying, challenging, and modifying dysfunctional
beliefs (e.g., magical thinking, inflated sense of responsibility for unwanted events,
overestimation of the probability of feared events, "thought-action fusion,"
perfectionism, belief that anxiety will persist forever, and need for control) may be
effectively combined with ERP.
The patient must be willing to do the work that CBT requires (e.g., regular
Psychodynamic psychotherapy may be useful in helping patients overcome their
resistance to accepting a recommended treatment and addressing the
interpersonal consequences of OCD symptoms.
Motivational interviewing may also help overcome resistance to treatment.
An SRI alone is recommended for a patient who has previously
responded well to a given drug or who prefers SRI
SRI alone may enhance cooperation with t/t by diminishing
symptom severity. SRI alone may also be considered in patients who
have severe OCD or are not otherwise able to cooperate with CBT.
An SRI alone may also be necessary if CBT is not accessible.
SSRIs have a less troublesome side effect profile than
clomipramine, an SSRI is preferred for a first medication trial.
Factors to consider when choosing among the SSRIs include
safety, side effects , acceptability , and potential interactions..
Combined treatment (SRI and CBT) is more effective than
monotherapy for some patients but is not necessary for all
should be considered for pts who have had an unsatisfactory
response to monotherapy, who have co-occurring psychiatric
conditions for which SRIs are effective, or who wish to limit
the duration of medication treatment.
Combined treatment for patients with severe OCD, since the
medication may diminish symptom severity and allow the
patient to engage in CBT.
C. Implementation of Treatment
Initiate pharmacotherapy at the dose recommended and titrate to
a maximally tolerable dose .
Patients who are worried about side effects can be started at halfdoses or less.
Lower doses and more gradual titration may be needed for patients
with co-occurring anxiety disorders and for elderly patients.
Evidence suggests that higher SSRI doses produce a somewhat
higher response rate and somewhat greater magnitude of symptom
Some patients may benefit from even higher doses than those
shown in the last column of Table 3. Monitor such patients closely
for side effects including serotonin syndrome.
There is no apparent relationship between OCD treatment outcome
and plasma levels of SRIs.
Continue pharmacotherapy for 8–12 weeks, including 4–6
weeks at a maximally tolerable dose.
Most patients will not experience substantial improvement
until 4–6 weeks after starting medication, and some who will
ultimately respond will experience little improvement for as
many as 10–12 weeks.
Patients who have not responded to a known effective dose
after 10–12 weeks may respond at higher doses.
Some clinicians prefer to titrate doses more rapidly (in weekly
increments to the maximum recommended dose if this is
comfortably tolerated) rather than waiting for 1–2 months
before each dose increment.
Manage medication side effects.
A first step is to consider if lowering the drug dose may alleviate the side effect
without loss of therapeutic effect.
Clomipramine is likely to induce anticholinergic effects, although these typically
diminish over time. Side effects may include delayed urination, weight gain and
sedation, orthostatic hypotension and postural dizziness, and cardiac arrhythmias
and seizures. Starting at a dose of 25 mg/day or less will increase early tolerability.
Common side effects of SSRIs and management strategies are described in Table 4.
Sexual side effects may affect one-third or more of patients taking SSRIs.
Carefully monitor patients taking SSRIs for suicidal thoughts and suicidal or other
self-harming behaviors, particularly during the early phases of treatment and after
A discontinuation syndrome consisting of dizziness, nausea/vomiting, headache,
and lethargy but also agitation, insomnia, myoclonic jerks, and paresthesias may
occur if medication is suddenly stopped. The syndrome may occur with any SRI but
is most often seen with paroxetine or the serotonin-norepinephrine reuptake
inhibitor venlafaxine. A slow taper over several weeks or more will minimize the
likelihood of discontinuation symptoms.
Fatigue or sleepiness
Add modest doses of modafinil.
Start with low doses.
Advise that mild queasiness or nausea will usually
disappear within 1–2 weeks at a constant dose.
Recommend taking the medication in the
Recommend sleep hygiene measures.
Add a sleep-promoting agent.
Reduce the dose to that which is minimally
Wait for the symptom to remit.
Sexual side effects
Recommend a once-weekly, one-day "drug
holiday" before engaging in sexual activity (not
effective for fluoxetine).
Switch to another SSRI.
Add a counteracting pharmacological agent (e.g.,
Add a low-dose anticholinergic agent such as
Provide CBT at least once weekly for 13–20 weeks.
The literature and expert opinion suggest that 13–20
weekly sessions with daily homework (or 3 weeks of
weekday daily CBT) is an adequate trial for most patients.
More severely ill patients may require longer treatment
and/or more frequent sessions.
Consider booster sessions for more severely ill patients,
patients who have relapsed in the past, and those who
show signs of early relapse.
The psychiatrist may conduct the CBT or refer the patient
for this or another adjunctive psychotherapy.
Monitor the patientâ€™ psychiatric status in follow-up visits.
The frequency of follow-up visits may vary from a few days to
2 weeks. The indicated frequency will depend on the severity
of the patient's symptoms, the complexities introduced by cooccurring conditions, whether suicidal ideation is present, and
the likelihood of troublesome side effects.
The patient should be encouraged to telephone between visits
if medication questions arise. If telephone calls become
reassurance rituals, work with the patient and the patient's
family to limit call frequency, using treatment as for any other
D. Changing Treatment
Decide when, whether, and how to alter the therapeutic plan
for patients who have continued OCD symptoms despite
First treatments rarely produce freedom from all OCD
symptoms, and there is typically opportunity for improvement.
Decisions about altering treatment may depend on the degree
of residual symptoms that a patient is willing to accept.
When patients are not motivated to pursue further treatments
despite limited improvement, consider if depressed mood is
diminishing hopefulness or if illness is associated with
Consider whether other factors are contributing to limited
improvement and address them:
Problems in the therapeutic alliance
Interference of co-occurring conditions such as panic
disorder, major depression, a substance use disorder, or severe
Inadequate adherence to treatment or failure to tolerate an
adequate trial of psychotherapy or medication at the
Family accommodation to symptoms
Consider extending or intensifying the
psychotherapeutic or pharmacological intervention.
If the patient continues to have an inadequate response
to treatment, consider the following alternatives:
Providing combined treatment (SRI and CBT)
Augmenting an SRI with an antipsychotic medication
Switching to a different SRI
Switching to venlafaxine
After the above treatments and augmentation strategies have been
exhausted, consider less well supported strategies.
Augmentation of SSRIs with clomipramine, buspirone, pindolol, riluzole, or onceweekly morphine sulfate.
Monotherapy with D-amphetamine, tramadol, MAOI ondansetron,TMS, or deep
brain stimulation may be considered.
Intensive residential treatment or partial hospitalization may be helpful for patients
with severe treatment-resistant OCD.
Ablative neurosurgery for severe and very treatment-refractory OCD is rarely
indicated and, along with deep brain stimulation, should be performed only at sites
with expertise in both OCD and these treatment approaches.
E. Discontinuing Treatment
Because relapse appears to be common, continue
treatment of some form for most patients.
Continue successful medication treatment for 1–2 years .
consider a gradual taper (of 10%–25% every 1–2 months)
while observing for symptom return .
Follow successful CBT consisting of ERP by monthly
booster sessions for 3–6 months