Obsessive-compulsive disorder

Definition

The major characteristics are recurrent obsessions (persistent intrusive thoughts) and compulsions (intrusive behaviors) which the patient experiences as involuntary, senseless, or repugnant.

Common obsessions include thoughts of violence (e.g., killing a loved one), obsessive slowness, fears of germs or contamination, and doubt (e.g., a priest who worries excessively that he had not said his prayers properly). Examples of compulsions include repeated checking to be assured that something was done properly, hand washing, extreme neatness, and counting rituals, as in numbering steps while walking.

Obsessions and compulsions do not invariably coexist in the same individual. The relationship of the obsessive-compulsive disorder to obsessive or compulsive characterologic traits remains controversial.

Etiology and pathophysiology

The etiology of the obsessive-compulsive state is uncertain, but it can be viewed from psychody-namic, psychosocial, and biologic perspectives. Obsessions and compulsions often seem to symbolize unconscious wishes, impulses, and fears and to reflect dynamic adaptations to unwanted aggressive or sexual urges. Biologic factors are suggested by reports of an increased incidence of obsessive compulsive disorder in monozygotic twins and first-degree relatives of probands, of biologic markers associated with the disorder, and of favorable response to certain tricyclic antidepressants and monoamine oxidase inhibitors.

Epidemiology

The lifetime prevalence of obsessive compulsive disorder, based upon interviews of the general population 18 years and older, varies between 1.9 and 3.0 percent. The prevalence tends to be slightly higher in females than males but does not vary significantly by race, education, or urbanization of area of residence.

Clinical manifestations

These disorders usually begin in adolescence or young adulthood, with about 65 percent of cases beginning before age 25. They are rarely seen in children. Clear prŠ¹cipitants are reported in up to 60 percent of cases. Long term prognosis appears to be variable. Some patients (perhaps 10 percent) show a chronic, unremitting course; some show periods of complete remission; the majority show an episodic course with periods of incomplete remission.

Complications

Depression is probably the most common secondary problem but anxiety, avoidant behavior, alcoholism, abuse of sleeping pills and tranquilizers, and impairment of social, marital, and occupational life can be marked.

Laboratory findings

No pathognomonic pathologic or laboratory abnormalities have been found.

Differential diagnosis

Repetitive self-destructive behaviors, such as gambling, drinking, drug abuse, and overeating, should not be diagnosed as “obsessive-compulsive” disorder since the individual normally derives pleasure from the activity. Stereotyped behavior is also common in schizophrenia, Tourette’s syndrome, and depression.

Treatment

Controlled studies have shown that both behaviorally oriented psychotherapy and psychopharmacology can be helpful in these disorders. Compulsions and rituals probably respond more than do obsessions and ruminations to behavior therapy. The tricyclic antidepressant drugs and monoamine oxidase inhibitors are relatively effective but require chronic administration. In severe unresponsive cases of obsessional-compulsive disorder cingulotomy or modified frontal leukotomy is reported to be helpful.