Obsessive-compulsive disorder

Obsessive thoughts and compulsive behaviors represent recurring efforts to control overwhelming anxiety, guilt, or unacceptable impulses that persistently enter the consciousness.

The word obsession refers to a recurrent idea, thought, impulse, or image that is intrusive and inappropriate and causes marked anxiety or distress.

A compulsion is a ritualistic, repetitive, and involuntary defensive behavior. Performing a compulsive behavior reduces the patient’s anxiety and increases the probability that the behavior will recur. Compulsions are commonly associated with obsessions.

Patients with obsessive-compulsive disorder are prone to abuse psychoactive substances, such as alcohol and anxiolytics, in an attempt to relieve their anxiety. In addition, other anxiety disorders and major depression commonly coexist with obsessive-compulsive disorder.
Obsessive-compulsive disorder is typically a chronic condition with remissions and flare-ups. Mild forms of the disorder are relatively common in the population at large.

Causes
The cause of obsessive-compulsive disorder is unknown. Some studies suggest the possibility of brain lesions, but the most useful research and clinical studies base an explanation on psychological theories. Several studies show brain abnormalities, such as decreased caudal size and decreased white matter, but results are inconsistent and remain under investigation. In addition, major depression, organic brain syndrome, and schizophrenia may contribute to the onset of obsessive-compulsive disorder.

Signs and symptoms
The psychiatric history of a patient with this disorder may reveal the presence of obsessive thoughts, words, or mental images that persistently and involuntarily invade the consciousness.
Some common obsessions include thoughts of violence (such as stabbing, shooting, maiming, or hitting), thoughts of contamination (images of dirt, germs, or feces), repetitive doubts and worries about a tragic event, and repeating or counting images, words, or objects in the environment. The patient recognizes that the obsessions are a product of his own mind and that they interfere with normal daily activities.
The patient’s history also may reveal the presence of compulsions, irrational and recurring impulses to repeat a certain behavior. Common compulsions include repetitive touching, sometimes combined with counting; doing and undoing (for instance, opening and closing doors or rearranging things); washing (especially hands); and checking (to be sure no tragedy has occurred since the last time he checked). The patient’s anxiety is often so strong that he’ll avoid the situation or the object that evokes the impulse.
When the obsessive-compulsive phenomena are mental, observation may reveal no behavioral abnormalities. However, compulsive acts may be observed, although feelings of shame, nervousness, or embarrassment may prompt the patient to try limiting these acts to his own private time.
You’ll need to evaluate the impact of obsessive-compulsive phenomena on the patient’s normal routine. He’ll typically report moderate to severe impairment of social and occupational functioning.

Diagnosis
Questionnaires, such as the Yale-Brown Obsessive Compulsive scale, may be used to help make the diagnosis.

Treatment
Treatment usually involves a combination of medication and cognitive behavioral therapy. Other types of psychotherapy may also be helpful.

Effective medications include clomipramine; tricyclic antidepressants; selective serotonin reuptake inhibitors, such as fluoxetine, paroxetine, sertraline, and fluvoxamine; and clonazepam, a benzodiazepine.

Behavioral therapies—aversion therapy, thought stopping, thought switching, flooding, implosion therapy, and response prevention—have also proved effective.