Obsessive Compulsive Disorder
A disorder characterized by recurrent, unwanted, intrusive ideas, images, or impulses that seem silly, weird,
nasty, or horrible (obsessions) and by urges to do something that will lessen the discomfort due to the obsessions
Obsessive-compulsive disorder occurs about equally in men and women and affects 1.6% of the population
during any 6-mo period.
Symptoms and Signs
The overarching obsessional theme is harm, risk, or danger, and common obsessions include contamination, doubt,
loss, and aggressivity. Typically, persons with obsessive-compulsive disorder feel compelled to perform repetitive,
purposeful, intentional behaviors called rituals to balance their obsessions: Washing balances contamination; checking,
doubt; and hoarding, loss. They may avoid persons they fear they may behave aggressively against. Persons can
obsess about anything, and rituals may not be logically connected to the obsessional discomfort they relieve.
For example, discomfort may have lessened spontaneously when a person who is worried about contamination
puts his hand in his pocket. Subsequently, he repeatedly puts his hand in his pocket whenever obsessions about
contamination arise. Most rituals, such as hand washing or checking locks, are observable, but some, such as
repetitive counting or statements under one's breath intended to diminish danger, are not.
Most persons with obsessive-compulsive disorder are aware that their obsessions do not reflect real risks
and that the physical and mental behaviors they perform to relieve their concern are unrealistic and excessive
to the point of being bizarre. Preservation of insight, although sometimes slight, differentiates obsessive-compulsive
disorder from psychotic disorders, in which contact with reality is lost.
Because persons with this disorder fear embarrassment or stigmatization, they often conceal their
obsessions and rituals, on which they may spend several hours each day. Depression is a common
secondary feature, present in about 1/3 of patients at the time of diagnosis and in 2/3 at some point in
Exposure therapy is effective; its essential element is exposure to situations or persons that trigger
obsessions, rituals, or discomfort. After exposure, rituals are delayed or prevented, allowing the anxiety
triggered by exposure to diminish through habituation. The patient learns that rituals are unnecessary to
decrease discomfort. Improvement usually persists for years, probably because patients who have
mastered this self-help approach continue to use it without much effort as a way of life after formal treatment
Many experts believe that combining behavior therapy and pharmacotherapy is the best treatment.
Potent serotonin reuptake inhibitors (SRIs), selective serotonin reuptake inhibitors (SSRIs--eg, fluoxetine,
fluvoxamine, paroxetine, sertraline), and clomipramine (a tricyclic antidepressant) are effective. For most SSRIs,
small doses (eg, fluoxetine 20 mg/day, fluvoxamine 100 mg/day, sertraline 50 mg) are as effective as large
ones. The minimum effective dose of paroxetine is 40 mg. Some data support the use of monoamine
oxidase inhibitors, but they are seldom indicated or needed because most patients respond to SRIs. Using
haloperidol to augment SRIs is effective for many patients with obsessive-compulsive disorder and tic
disorders (eg, Tourette syndrome). Augmentation with atypical antipsychotics may help patients without