Click here to view next page of this article


Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is a common illness.   The fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) requires that a patient have either obsessions or compulsions that are a significant source of distress; are At some point during the course of the illness, the adult patient must recognize that the obsessions or compulsions are According to DSM-IV, obsessions are defined by the following features:

Recurrent and persistent thoughts, impulses, or images that are experienced at some time during the disturbance as intrusive and inappropriate and that cause marked anxiety. Thoughts, impulses, or images that are not simply excessive worries about. Attempts to ignore or suppress such thoughts or impulses or to neutralize them with some other thought or action. Recognition that the obsessional thoughts, impulses, or images are a product of one's own mind, not imposed from without as in thought insertion.

Clinically, the most common obsessions are repetitive thoughts of violence (for example, killing one's child), contamination (for example, becoming infected by shaking hands).

Compulsions are defined as follows: Repetitive behaviors that the person feels driven to perform in response to an obsession.


Centuries ago, persons with obsessive blasphemous or sexual thoughts were considered to be possessed. That religious view of obsessions was consistent with the contemporary world view, and the logical treatment was designed to expel evil from the unfortunate soul who was possessed.



Even within the past decade, OCD was considered to be extremely rare (approximately 0.05 percent of the population). But more recent studies, including the Epidemiologic Catchment Area study.


The mean age of onset for OCD in one study was in the early 20s, with over half of the patients becoming symptomatic by age 25, and three quarters by age 30.



In rare cases, one can identify a brain insult, such as encephalitis or head injury, as an antecedent to OCD, but typically there is no identifiable neurological precipitant.


There is evidence that serotonin-specific reuptake inhibitors (SSRIs) are partially effective treatments for OCD. In one study comparing clomipramine (Anafranil) to nortriptyline (Aventyl) and placebo, only clomipramine was significantly superior to placebo in reducing OCD symptoms. In addition, response to clomipramine was strongly correlated with lowering of cerebrospinal fluid (CSF) concentrations.

Other Neurotransmitters

A number of studies support the hypothesis that the serotonergic system is not the only system involved in the pathophysiology of OCD. The clinical ineffectiveness of the potent serotonergic agent, zimelidine, and of the anxiolytic 5-HT1A partial agonist buspirone (BuSpar), for example, are difficult to explain.


Although psychoanalysis and psychodynamically oriented psychotherapy are not effective in the treatment of obsessions and compulsions, a number of interesting hypotheses are raised by theorists in that area.


Isolation is a defense mechanism that protects an individual from anxiety-provoking affects and impulses. Under ordinary circumstances, an individual experiences in consciousness both the affect and the imagery of an emotion-laden idea, whether it be a fantasy or the memory of an event. When isolation occurs, the affect and the impulse from which it derives are separated from the ideational component and pushed out.


Nemiah and Uhde noted that, in the face of the impulse's constant threat to escape the primary defense of isolation, further defensive operations are required to combat the impulse and to quiet the anxiety aroused by its imminent eruption into consciousness.



OCD patients usually present with specific complaints, such as pronounced obsessions or compulsive rituals, that allow the clinician to make the diagnosis easily. With nonpsychiatric physicians and even with psychiatrists who do not specialize in anxiety disorders, patients may be reluctant to discuss symptoms that they find embarrassing or disgusting.


Symptoms can usually be placed into one of several categories: checking rituals, cleaning rituals, obsessive thoughts, obsessional slowness, or mixed rituals. Checking and cleaning rituals are the most common and multiple symptoms are the rule.

Cleaning compulsions
Checking compulsions
Primary obsessional disorder


The mean age of onset of OCD is between ages 20 and 24; over 80 percent of patients develop symptoms before age 35. Some patients describe the onset of symptoms after a stressful event.


The treatment of patients suffering from OCD is an example of the need to integrate various approaches to maximize patient outcome. They must generally receive medication in combination with other approaches, particularly behavior therapy.


In the absence of any adequate studies of psychotherapy for OCD.


The typical randomized prospective placebo-controlled trial, which proved so useful in depression research, was until recently almost impossible because of the small numbers of OCD patients.

Cyclic and atypical antidepressants

Case reports of successful treatment of OCD have involved almost every antidepressant on the market, including imipramine (Tofranil), clomipramine, amitriptyline (Elavil, Endep), doxepin (Adapin, Sinequan).

The best studied antiobsessional agent is clomipramine, a tricyclic antidepressant.

Monoamine oxidase inhibitors

Anecdotal evidence suggests that MAOIs are particularly helpful for patients who suffer concomitantly.


One double-blind crossover trial of six OCD patients carried out in Denmark reported that lithium (Eskalith).

Obsessive-compulsive behaviors are sometimes found in patients suffering from bipolar disorder. A recent report of two patients who met criteria for both disorders, who were treated.


A few studies report that ECT in combination with other treatment modalities.


With the advent of restricted and relatively safe psychosurgical operations, such as cingulotomy.


The behavioral techniques most consistently effective in reducing compulsive rituals and obsessive thoughts are exposure to the feared situation or object, and response prevention, in which the patient resists the urge to perform the compulsion after exposure. Simple relaxation therapy is an ineffective treatment for OCD.