Obsessive-compulsive disorder (OCD) is
an type of anxiety disorder , represented by
a diverse group of symptoms that include
intrusive thoughts, rituals, preoccupations,
These recurrent obsessions or compulsions
cause severe distress to the person. The
obsessions or compulsions are time-consuming
and interfere significantly with the person's
normal routine , occupational functioning,
usual social activities, or relationships. A
patient with OCD may have an obsession, a
compulsion, or both.
An obsession is a recurrent and intrusive thought, feeling, idea, or sensation.
In contrast to an obsession, which is a mental event, a compulsion is a
Specifically, a compulsion is a conscious, standardized, recurrent behavior,
such as counting, checking, or avoiding.
A patient with OCD realizes the irrationality of the obsession
and experiences both the obsession and the compulsion as ego-dystonic.
the compulsive act may be carried out in an attempt to reduce
the anxiety associated with the obsession, it does not always
succeed in doing so.
The completion of the compulsive act may not affect the
anxiety, and it may even increase the anxiety.
Anxiety is also increased when a person resists carrying out a
a lifetime prevalence in the general population
estimated at 2 to 3 percent.
Some researchers have estimated that the disorder is
found in as many as 10 percent of outpatients in
OCD is the fourth most common psychiatric
diagnosis after phobias, substance-related disorders, and
major depressive disorder.
Among adults, men and women are equally likely to
be affected, but among adolescents, boys are more
commonly affected than girls.
mean age of onset is about 20 y.o, although men
have a slightly earlier age of onset (mean about 19
years) than women (mean about 22 years).
about two thirds of affected persons have an onset
before age 25, and the symptoms of fewer than 15
percent have an onset after age 35.
Single persons are more frequently affected with
OCD than are married persons, although this finding
probably reflects the difficulty that persons with the
disorder have maintaining a relationship .
OCD occurs less often among blacks than among
Lifetime prevalence for major depressive
disorder in persons with OCD is about 67
percent and for social phobia, about 25 percent.
The incidence of Tourette's disorder in
patients with OCD is 5 to 7 percent, and 20 to 30
percent of patients with OCD have a history of
Other common comorbid psychiatric
diagnoses in patients with OCD include alcohol
use disorders, generalized anxiety disorder,
specific phobia, panic disorder, eating disorders,
and personality disorders.
dysregulation of serotonin is involved in the symptom formation
of obsessions and compulsions in the disorder.
Data show that serotonergic drugs are more effective than drugs
that affect other neurotransmitter systems.
Clinical studies have assayed CSF concentrations of serotonin metabolites
(e.g., 5-hydroxyindoleacetic acid [5-HIAA]) and affinities and numbers of
platelet-binding sites of tritiated imipramine , which binds to serotonin
reuptake sites, and have reported variable findings of these measures in
patients with OCD. In one study, the CSF concentration of 5-HIAA decreased
after treatment with clomipramine , focusing attention on the serotonergic
Currently, less evidence exists for dysfunction in the
noradrenergic system in OCD. Anecdotal reports show some
improvement in OCD symptoms with use of oral clonidine, a
drug that lowers the amount of norepinephrine released from the
presynaptic nerve terminals.
Some interest exists in a positive link between
streptococcal infection and OCD. Group A β-
hemolytic streptococcal infection can cause
rheumatic fever, and approximately 10 to 30
percent of the patients develop Sydenham's
chorea and show obsessive-compulsive
Neuroimaging in patients with OCD has produced converging data
implicating altered function in the neurocircuitry between orbitofrontal
cortex, caudate, and thalamus.
PET SCANS shows - increased activity (e.g., metabolism and blood flow)
in the frontal lobes, the basal ganglia (especially the caudate), and the
cingulum of patients with OCD.
Pharmacological and behavioral treatments reportedly reverse
Neuroimaging – area involved in OCD theory .
In CT-Scans studies have found bilaterally smaller
caudates in patients with OCD.
MRI study reported increased T1 relaxation times in
the frontal cortex, a finding consistent with the location
of abnormalities discovered in PET studies .
Some studies demonstrate increased rates of a
variety of conditions among relatives of OCD probands,
including generalized anxiety disorder, tic disorders,
body dysmorphic disorder, hypochondriasis, eating
disorders, and habits such as nail-biting.
Other Biological Data
A higher than usual incidence of nonspecific EEG abnormalities occurs
in patients with OCD.
Sleep EEG studies have found abnormalities similar to those in
depressive disorders, such as decreased rapid eye movement latency.
Neuroendocrine studies have also produced some analogies to
depressive disorders, such as non-suppression on the dexamethasone-
suppression test in about one third of patients and decreased growth hormone
The Learning Theory – the patient getting trapped in the
OCD cycle .
OCD differs from obsessive-compulsive personality disorder, which is
associated with an obsessive concern for details, perfectionism, and
other similar personality traits. Most persons with OCD do not have
premorbid compulsive symptoms, and such personality traits are
neither necessary nor sufficient for the development of OCD. Only
about 15 to 35 percent of patients with OCD have had premorbid
Many patients refuse to cooperate with SSRI treatment and CBT , and become
invested in symptomatology due to secondary gain , child who want to obtain
attention from his mother .
And patient learn how there illness can effect others – mainly faced in families
with disrupted interpersonal relationship .
OCD patient engage in compulsion pattern in Away to relieve stressors of
daily life – environmental stressors , pregnancy , child care .
Sigmund freud theory
Obsessive-Compulsive Neurosis considered a regression from the oedipal
phase to the anal psychosexual phase of development – OCD patient feels
threatened by the anxiety about unconsciousness impulses or loss of love
object which to an intensity ambivalence emotional stage with the anal phase ,
the coexistence of hatred and love toward same person leave patient paralyzed
with doubt and indecision .
Freud believed the need to be clean and not to be touched is related to anal
sexuality , and the disgust for the mother is the reaction against that fear .
The disturbances may lie between normal development and anal-sadistic
In magical thinking, regression uncovers early modes of thought rather
than impulses; that is, ego functions, as well as id functions, are
affected by regression. Inherent in magical thinking is omnipotence of
thought. Persons believe that merely by thinking about an event in the
external world they can cause the event to occur without intermediate
physical actions. This feeling causes them to fear having an aggressive
And Symptom Patterns
Most of the patients with OCD have both obsession and compulsion – up to
75% both are presented in some survey , some clinicians believes that it’s can
reach close to 100% if the patient is asses carefully .
Example – obsession about hurting children can accompanied in specific
prayers to prevent that .
Some patients who have only obsession without compulsion , mostly have
repetitious thoughts of sexual or aggressive act .
And Symptom Patterns
OCD patient mostly have an anxious feeling , because they recognize that all
of there obsession are an ego-alien , but they cannot get rid of them .
OCD patient can present to other medical specialists before presenting to a
Dermatologist – chapped hand , eczematoid hand .
Oncologist – insistent beliefs that they aquired some type of tumor .
Infectious disease – infectious with HIV .
Pediatrician – sydenhams chorea .
Dentist – gum lesion .
And Symptom Patterns
The most common symptomatic pattern :
.1Contamination – the most common obsession , obsession of
contamination followed by compulsive avoiding of contaminated objects ,
excessive cleaning , inability to leave there homes because of fear of
germs , shame and disgust from feces , urine , dust and germs .
.2Pathological doubt – 2nd most common , obsession of doubt , followed
buy compulsive checking , most danger of violence , forgetting to turn off
the stove , or not locking the door , some patient can travel back home
several times . Obsession of self-doubt , feeling guilty about issues .
And Symptom Patterns
Intrusive thoughts – 3rd most common , intrusive obsessional thoughts without
compulsion , such as repetitive sexual or aggressive acts , patients obsessed of
there thoughts , may think that they suppose to report them to the police or to
make a confession to the priest .
Symmetry – 4th most common , the need for symmetry of precision , which
lead them to compulsion of slowness , patient can take an hour to eat a meal or
shave their faces .
And Symptom Patterns
Other symptoms pattern –
Religious obsession and compulsive hoarding .
Trichitillomnia – compulsive hair pulling and nail biting .
Masturbation can be an compulsive pattern , in many way to relief specific
obsessive anxiety .
Not a fixed belief , ego-
dystonic , not accompanied
OCD and delusional disorder
Basal ganglia mostly involved
and another symptomatic
pattern are present such as
sydenhams chorea .
Idiopathic OCD And OCD-like
Must present before 18 y.o ,
at least 1 year pattern of
multiple motor and one or
more vocal tics , never tics
free of 3 months or more .
Coprolalia and echolalia can
OCD and Tourettes Disoder
Personality traits are ego-
syntonic , present before 18
y.o , no true syndrome of
obsession and compulsion .
OCD and obsessive-
Patient have insight to there
symptoms , no other features
of psychosis (delusion ,
OCD and obsessive thoughts
Obsessive thoughts present
during depression episode ,
while in OCD they persist .
OCD and depression
OCD symptoms appears to be refractory to psychodynamic
psychotherapy , and psychoanalysis , pharmacological and behavioral
treatment considered better approaches .
The standard approach are start treatment with An SSRI or
Clomipramine , and then move forward to other pharmacological
therapies if serotonin specific drugs are not effective .
* Initial effect generally seen after 4-6 weeks of treatment , although 8-16
weeks are usually needed to obtain maximal therapeutic benefits .
SSRI – Fluoxetine , Fluvoxamine , Paroxetine , Citalopram – all are
approved by FDA for OCD treatment .
Common side effect – sleep disturbances , nausea , diarrhea , headache ,
restlessness , anorgasmia . Most of this side effect are transient .
Best clinical outcome occur when SSRI are combined by CBT .
Clomipramine (tricyclic anti-depressant) – 1st drug approved by FDA for
OCD treatment , side effects includes : G.I disturbances , orthostatic
hypotension , sedation , anticholinergic side effects included dry mouth
and constipation . As with SSRI best outcome is with combined behavioral
Other pharmacotherapy which used for first augmentation in case of
resistance cases –
Other drugs which could be tried – Venelafaxine , pindolol , MAOI
phenelzine , buspirone , 5-hydroxytryptamine , l-tryptophan , clonazepam
Atypical anti-psychotic such as Risperidol , helped in some cases .
Pharmacotherapy and behavioral therapy has long lasting effect .
The principle of the therapy is –
Exposure and response prevention
Desensitization and thoughts stopping
Aversive conditioning .
Psychotherapy with concentrating in Cognitive behavioral therapy , and
insight oriented therapy , also can be combined by supportive therapy .
Treatment – other
Family therapy – building alliance with the family members , and helping
reduce marital discord resulting from the disorder .
Group therapy – can be tried .
•For extreme cases that treatment resistant and chronically debilitating
– ELECTROCONVULSIVE THEAPT (ECT) and psychosurgery are
the consideration .
Treatment – other
•Cingulotomy which is successfully treating 25-30 percent of
unresponsive cases .
•Subcaudate tractotmy (capsulotomy) also has been used for that
Non ablative surgical techniques involving indwelling electrodes in
various basal ganglia (deep brain stimulation ) are under investigation
patient who is suffering from Tourettes disorder and OCD .
Seizures development due to Psychosurgery , mostly can be eliminated by
Nature is not only all that is visible to the eye... it also includes the
inner pictures of the soul.
- Edvard Munch
Anxiety, 1894 , The Scream, 1893 , The Dance of Life, 1899 , by Edvard Munch