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Symptoms and Signs

Obsessions are repetitive, intrusive ideas, images, or impulses. Obsessions commonly focus on harming others, acquiring or spreading contamination, doubt about having performed routine tasks properly, and transgressing social norms (eg, making unacceptable sexual

Compulsive rituals are repetitive thoughts or acts usually performed to decrease anxiety or other discomfort associated with obsessions. The acts may be sensible in the abstract, but the frequency and duration of their repetition make them repugnant and inconvenient, even

Attempts are usually made to resist rituals, although children and those who have been performing rituals for years may

If prevented from carrying out a ritual, obsessive compulsive individuals frequently become

Rituals are usually preceded by obsessions, but obsessions do not always lead to rituals. Rituals of cleaning, repeating, checking, tidying, hoarding, and avoiding may consume almost

Differential Diagnosis

A classical picture of obsessive-compulsive disorder (OCD) can emerge as a secondary complication of major depression. Obsessions alone may appear in the context of either depression or schizophrenia, and the distinction between obsessions and delusions can be

There is a tendency to overdiagnose delusions and underdiagnose obsessions. Other attributes of schizophrenia are usually absent in patients with obsessive-compulsive disorder, although some of these patients also suffer from schizotypal personality disorder, which worsens the prognosis.

Obsessive-compulsive disorder can usually be differentiated from phobias in the following ways:

1. Phobics are more fearful about confronting the feared object than are obsessive-compulsives, who are usually more concerned about the rituals they will face because of contact with the

2. The fears of phobics are usually less complex than those of obsessive-compulsives. Phobic fears are more typically focal (eg, fear of fainting while having blood drawn) than those of obsessive-compulsives (there are

3. Anxiety of phobics is usually greater than that exhibited by obsessive-compulsives when both confront the things they fear.

So-called "compulsive" behaviors such as eating, hair pulling, dysmorphophobia, drug taking, and excessive checking with doctors are not considered OCD if the content of obsessions or compulsions is restricted to that disorder (eg, preoccupation with food in the presence of an


Dysfunction is defined in terms of the amount of time consumed by obsessions and rituals, interference with functioning, control over obsessions and rituals, and the amount of suffering endured. The disorder usually lasts for decades once it has begun and runs an undulating course, worsening


In one-third of obsessive-compulsive individuals, onset of the disorder occurs by the age of 15. A second peak of incidence occurs during the third decade of life. Once established, obsessive-compulsive disorder is likely to persist throughout life with varying degrees of severity. Men are

Etiology & Pathogenesis

Obsessive-compulsive disorder clusters in families and appears to have a partly hereditary basis.

Once an obsessive thought intrudes, the forces maintaining its recurrence are uncertain. Efforts to demonstrate meaningful linkages between obsessions and unconscious conflict have failed to yield useful treatment techniques or to persuade many psychiatrists that such hypotheses have

The biochemical and anatomic bases of obsessive-compulsive disorder have not been fully defined, but present research suggests that among any


Behavioral therapy employing exposure and prevention of ritualistic responses yields a 60-80% reduction in symptoms for the three-fourths of patients who are able to comply with treatment instructions. Family members are often included as cotherapists. They are instructed to praise

Drug Therapy:

Most antidepressants do not appear to have specific anti-obsessive-compulsive properties, but clomipramine and other potent serotonin uptake inhibitors (fluoxetine, fluvoxamine, and sertraline proven; paroxetine, probable) do have

Anxiolytics-Antianxiety medications have a limited role in the long-term treatment of obsessive-compulsive disorder but are

Antipsychotic drugs-Antipsychotic medications are unlikely to be beneficial except for patients with

Other Treatment:

Electroconvulsive therapy is sometimes helpful in individuals with severe primary depression and secondary obsessions and

Psychotherapy-Some obsessive-compulsive patients are still treated with dynamic psychotherapy, often for many years, without manifest relief or improvement in functioning. Psychotherapists often point to "intrapsychic" benefits in patients who

Neurosurgery-Stereotactic limbic leukotomy (combining anterior cingulotomy and subcaudate tractotomy) and anterior