Study Points

Obsessive-Compulsive Disorder

Course #96472 - $16 • 4 Hours/Credits

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  1. It is estimated that how many adults in the United States are affected by obsessive- compulsive disorder (OCD)?

    EPIDEMIOLOGY

    The exact prevalence of OCD is unknown. The National Comorbidity Survey Replication (NCS-R), a nationally representative household survey designed to assess the prevalence, severity, and comorbidity of various psychiatric disorders in the United States, found that OCD affects roughly 2.2 million American adults, or about 1% of adults in any given year [2,4]. The NCS-R researchers used criteria from the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) to make the diagnosis, based on responses to a version of the World Health Organization's Composite International Diagnostic Interview (CIDI). The Epidemiologic Catchment Area Study, conducted in the 1980s, found an OCD lifetime prevalence of 1.94% to 3.29% across five study sites [5]. This study employed lay interviewers to administer the National Institute of Mental Health Diagnostic Interview Schedule (DIS). However, the reliability of the DIS-based diagnosis is open to question; at re-interview 12 months later, only 19.2% of patients who met OCD criteria on initial interview admitted to ever having had OCD-criteria symptoms.

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  2. In the DSM-5, OCD is classified as a(n)

    DIAGNOSTIC CRITERIA

    The first step in correctly diagnosing and treating OCD is understanding its definition. Although previously considered an anxiety disorder, OCD is classified as an obsessive-compulsive disorder in the fifth edition of the DSM (DSM-5) along with other related conditions, including body dysmorphic disorder, hoarding disorder, trichotillomania, and excoriation disorder. Essentially, OCD involves obsessions and/or compulsions that cause distress or interfere with functioning. The obsessions are usually associated with anxiety, and compulsions often serve to ameliorate that anxiety. People with the disorder are usually aware, at least at some point in time, that their obsessions or compulsions are not reasonable.

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  3. Which of the following is NOT among the acts that define the obsessions and compulsions that occur with OCD?

    DIAGNOSTIC CRITERIA

    The DSM-5 definition of OCD is based on four criteria [14]. The first criterion is the presence of either obsessions or compulsions. Obsessions are defined by [14]:

    • Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted and cause marked anxiety or distress in most individuals.

    • The person attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action.

    Compulsions are defined by:

    • Repetitive behaviors (e.g., handwashing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.

    • The behaviors or mental acts are aimed at preventing or reducing anxiety or distress or preventing some dreaded event or situations; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive. Note: Young children may not be able to articulate the aims of these behaviors or mental acts.

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  4. Aside from the pressure of obsessions or compulsions, a diagnosis of OCD also requires that the patient display

    DIAGNOSTIC CRITERIA

    Secondly, diagnosis of OCD is dependent upon disruption of day-to-day life. The obsessions or compulsions are time consuming (take more than one hour per day) or significantly interfere with the person's normal routine, occupational (or academic) functioning, usual social activities or relationships, or other important areas of functioning.

    The third diagnostic criterion is that the disturbance is not due to the direct physiologic effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

    Disease-specific manifestations are the fourth criterion. In order for OCD to be diagnosed in patients with another Axis 1 disorder, the content of the obsessions or compulsions may not be restricted to the other disorder (e.g., preoccupation with food in the presence of an eating disorder; hair pulling in the presence of trichotillomania; concern with appearance in the presence of body dysmorphic disorder; preoccupation with having a serious illness in the presence of hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a paraphilia; or guilty ruminations in the presence of major depressive disorder).

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  5. The cause of OCD has not yet been identified. Research has indicated that which of the following neurotransmitters may be involved?

    PATHOPHYSIOLOGY

    Another hypothesis regarding the underlying cause of OCD involves serotonin. Research regarding a role for serotonin was spurred by studies of the effectiveness of antidepressants, such as clomipramine and desipramine, for OCD in non-depressed patients [20,23]. Clomipramine, which acts primarily as a serotonin reuptake inhibitor (SRI), has proved to be more effective than desipramine, which is thought to act primarily by inhibiting norepinephrine reuptake [24]. The ability of selective serotonin reuptake inhibitors (SSRIs) to reduce OCD symptoms further supports a role for serotonin abnormalities in the pathogenesis of OCD, a theory supported by the 2017 study in which a gene that includes a serotonin receptor, HTR2A, was found to be among the most commonly associated in those with OCD [71]. A specific mechanism, however, has not been elucidated, and studies involving measures of serotonergic function have been inconsistent.

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  6. Obsessive-compulsive personality disorder may be differentiated from OCD by

    DIFFERENTIAL DIAGNOSIS

    OCPD is characterized by preoccupation with order, perfection, and control, but not by the presence of obsessions or compulsions [15]. It is often compared to a "perfectionist" personality. Unlike OCD, symptoms must appear by early adulthood for the diagnosis to be made; however, OCD and OCPD may occur in the same person. The frequency of both diagnoses occurring together is not known, but studies suggest that it is not uncommon [26]. Estimates from OCD study populations indicate a concomitant rate between 23% and 32%, although these samples were not designed to be representative of all patients with OCD [26,73]. For comparison, the prevalence of OCPD has been observed to be about 0.9% to 2% in community samples [26,73]. There is also some evidence that OCPD is more common in people with OCD than in patients with other psychiatric disorders.

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  7. Which of the following conditions is a common comorbidity with OCD?

    COMORBIDITIES

    Depression is a particularly common comorbidity. A chart review of 120 patients with OCD in the Netherlands found depression in one-third, and a separate structured psychiatric interview found similar results (31%) for major depression [29,74]. The Epidemiologic Catchment Area Study in the United States found 67% of individuals identified as having OCD had at least one episode of major depression [27]. In addition, OCD has been shown to comorbidly occur with social phobia (11%), simple phobia (including body dysmorphic disorder) (7%), and panic disorder (6%). Associations have also been observed between OCD and other conditions, including bipolar disorder, eating disorder, generalized anxiety disorder, alcohol dependence/substance abuse, and Tourette syndrome [6,30]. Richter and colleagues looked at patients with OCD, social anxiety disorder, or panic disorder and found that trichotillomania, skin picking, body dysmorphic disorder, and tics were more strongly associated with OCD than with the other two anxiety disorders [31].

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  8. Which selective serotonin reuptake inhibitors (SSRIs) have FDA-approved indications for the treatment of OCD?

    TREATMENT

    Five SRIs are approved by the U.S. Food and Drug Administration (FDA) for OCD treatment, including four SSRIs and one serotonin-specific tricyclic antidepressant (TCA):

    • Fluoxetine

    • Fluvoxamine

    • Paroxetine

    • Sertraline

    • Clomipramine

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  9. Clomipramine is a(n)

    TREATMENT

    Five SRIs are approved by the U.S. Food and Drug Administration (FDA) for OCD treatment, including four SSRIs and one serotonin-specific tricyclic antidepressant (TCA):

    • Fluoxetine

    • Fluvoxamine

    • Paroxetine

    • Sertraline

    • Clomipramine

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  10. Compared with their use in depression, SRIs in OCD

    TREATMENT

    Although clomipramine and the SSRIs are also used to treat depression, their use in OCD has somewhat different parameters. Patients with OCD may require higher doses, and the onset of action may be slower. In depression, improvement may be expected as early as one week after initiating treatment. The APA guideline for the treatment of major depressive disorder recommends re-evaluating treatment if at least moderate improvement has not occurred after six to eight weeks [6]. In OCD, a full trial of SRI therapy takes 8 to 12 weeks, including 4 to 6 weeks on the highest tolerable dose [77].

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  11. Assuming that the patient is able to comfortably tolerate the medication, a full trial of an SRI for a patient with OCD should last for

    TREATMENT

    Although clomipramine and the SSRIs are also used to treat depression, their use in OCD has somewhat different parameters. Patients with OCD may require higher doses, and the onset of action may be slower. In depression, improvement may be expected as early as one week after initiating treatment. The APA guideline for the treatment of major depressive disorder recommends re-evaluating treatment if at least moderate improvement has not occurred after six to eight weeks [6]. In OCD, a full trial of SRI therapy takes 8 to 12 weeks, including 4 to 6 weeks on the highest tolerable dose [77].

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  12. The usual target dose of fluoxetine for patients with OCD is

    TREATMENT

    ADULT DOSING OF SSRIs FOR THE TREATMENT OF OCDa

    SSRIStarting and Incremental DoseUsual Target DoseUsual Maximum DoseOccasionally Prescribed Maximum Dose
    Citalopram20 mg40 mgb40 mgb40 mgb
    Escitalopram10 mg10–20 mg40 mg60 mg
    Fluoxetine20 mg40–60 mg80 mg120 mg
    Fluvoxamine50 mg100–300 mg300 mg450 mg
    Paroxetine20 mg20–60 mg60 mg100 mg
    Sertraline50 mg200 mg200 mg400 mg
    aDosages are for immediate-release formula, not controlled-release.
    bMaximum dose: 40 mg
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  13. Which SSRI is thought to have the most anticholinergic side effects?

    TREATMENT

    In some cases, lowering the dose, changing the timing of doses, or changing to a different SRI will help to alleviate side effects; in others, adding an additional medication may be helpful [6]. Some side effects are particularly likely with certain SSRIs. For example, paroxetine is the most anticholinergic and appears to be more likely to cause weight gain than other SSRIs. Insomnia may be addressed by taking the SSRI in the morning instead of the evening or by the addition of a sleep-promoting agent. Modafinil may help with fatigue. Excessive diaphoresis may be improved by the addition of a low-dose anticholinergic.

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  14. Some patients experience sexual side effects, including loss of libido and trouble achieving orgasm, when using SSRIs. Options for addressing sexual side effects include

    TREATMENT

    Sexual symptoms, including decreased libido and difficulty with orgasm, may be difficult to overcome, but there are options that will work for some patients. In some cases, sexual symptoms will decrease over time. Some patients may be willing to wait until OCD symptoms have improved and weaning from the SSRI is appropriate. Some may benefit from a "drug holiday" up to once per week, stopping the SSRI for one day before a sexual encounter. In general, stopping an SSRI abruptly is not recommended due to the possibility of withdrawal effects, but with most of the SSRIs, missing one dose is not expected to affect outcomes adversely. The short half-life of paroxetine makes it a poor choice for this technique, and the half-life of fluoxetine may be too long for the one-day "holiday" to be useful.

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  15. When a trial of SSRI monotherapy does not provide any improvement, which of the following is recommended by the APA as a possible next step?

    TREATMENT

    As noted, the APA recommends a trial of at least 8 to 12 weeks with a given SRI, including at least four to six weeks at the highest tolerable dose [6]. For patients who fail to achieve a reduction in symptoms by the end of this time or who have only minimal response, there are several APA-recommended options [6]. One strategy is to offer a trial of a different SSRI. It may take multiple trials to find the right match for a given patient. Additional options include switching to clomipramine, switching to the serotonin-norepinephrine reuptake inhibitor venlafaxine, or adding a second-generation antipsychotic. Switching to mirtazapine is also offered as a strategy, although supporting evidence is limited. Switching to venlafaxine may be less effective than switching to a different SRI.

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  16. When SRI therapy is helpful, expert consensus is that the medication should be continued for at least

    TREATMENT

    The best duration for pharmacotherapy in OCD has not been determined. A minimum of one to two years has been recommended before withdrawal should be considered [6,57]. The decision to continue or to stop medication should be individualized and discussed with each patient.

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  17. The type of psychologic therapy with the best evidence for efficacy in OCD is

    TREATMENT

    Of all potential psychologic therapies for OCD, CBT is supported by the best evidence. Most studies have used some form of exposure and response prevention as the mode of therapy, with variations in frequency, intensity, and guidance. These studies have generally been small, with at most a few dozen patients. One larger, multisite trial compared exposure and response prevention to clomipramine, placebo, or a combination of the two treatments [58]. This study involved intensive, daily exposure and response prevention for four weeks, followed by maintenance sessions for another eight weeks. Overall, 71% of the 122 randomized patients completed treatment. Response rates at week 12, measured as improvement on the Y-BOCS, CGI-S, and NIMH-GOCS, were all significantly better for exposure and response prevention than for clomipramine. Exposure and response prevention plus clomipramine was not significantly better than exposure and response prevention alone. Based on the CGI-I measure, an "excellent" response was seen more often in the exposure and response prevention group and in the combination group than in the clomipramine-alone group.

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  18. Exposure and response prevention involves

    TREATMENT

    Exposure and response prevention consists of a specific series of techniques. It may be offered as individual therapy or in a group setting. The APA recommends at least weekly sessions [6].

    Exposure and response prevention is based on the idea that obsessions and compulsions serve to reinforce one another [62,63]. The obsessions are associated with great anxiety; because compulsions serve to reduce that anxiety, the performance of these behaviors is reinforced with each cycle. At the same time, the use of ritualized behaviors to combat anxiety prevents the development of other methods of coping with the anxious feelings. Thus, repeated exposure to a feared stimulus while avoiding the use of ritualized behavioral responses should, over time, lead to a dampening of the anxiety response and a lessening of the need to perform compulsions. Exercises generally start with exposure to a situation that causes a moderate level of anxiety and progress to exposures that are more intensely feared. Patients are encouraged to think about the feared consequences of not performing their rituals. At the same time, they are asked to abstain from these ritualistic behaviors and encouraged to develop alternative ways of tolerating and overcoming anxiety. When exposure and response prevention is successful, patients gradually become accustomed to the idea that feared outcomes are unlikely to happen even though rituals are not performed.

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  19. When CBT is effective, expert consensus on the recommended duration of weekly sessions is

    TREATMENT

    There is no strong evidence to support a given duration of CBT. However, the consensus, according to the APA guideline, is for an initial course of 13 to 20 weeks of weekly CBT or three weeks of daily sessions [6]. If treatment is successful, it may be tapered to monthly sessions for another three to six months. Some patients will benefit from occasional booster sessions as well. The APA recommends ongoing maintenance, although details are not specified [6]. The exact probability of relapse following CBT is unclear.

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  20. Patients who are so disabled by OCD symptoms that they are unable to participate in standard treatments should be

    TREATMENT

    Some patients will fail to respond to both standard pharmacologic options and to outpatient CBT. Others will achieve a partial response but remain unable to return to a satisfactory level of functioning. A subset of patients will be so disabled by symptoms that they are unable to participate in standard outpatient treatment. These patients should generally be referred to specialty psychiatric care, preferably to a physician with expertise in OCD.

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