Obsessive-compulsive disorder
Obsessive-compulsive disorder (OCD) is defined by ego-dystonic obsessions and/or compulsions that are time-consuming or cause significant distress and functional impairment, distinguishing it from the ego-syntonic perfectionism of obsessive-compulsive personality disorder. Diagnosis is clinical. First-line treatment combines cognitive behavioral therapy using exposure and response prevention with a high-dose selective serotonin reuptake inhibitor, with clomipramine as an effective second-line tricyclic and an OCD trial that can take up to 10 weeks to judge full response.
- Topic reviewThe full article, organized the way the exam asks it.
- ABIM-format MCQsVignettes with an explanation for every wrong answer.
- Key factsThe numbers and thresholds worth memorizing, up front.
- AI tutorMedBrain answers the question you're stuck on.
What this article covers
- Overview
Definition: obsessive-compulsive disorder (OCD) is characterized by obsessions, compulsions, or both, that are time-consuming (typically more than 1 hour per day) or cause significant distress and…
- Epidemiology
Lifetime prevalence: approximately 2%. Sex distribution: prevalence is roughly equal in male and female patients.
- Risk factors
Comorbid tic disorders: OCD is strongly associated with tic disorders, including Tourette syndrome.
- Pathophysiology
Cortico-striato-thalamo-cortical (CSTC) circuit dysfunction: the CSTC circuit has been implicated in OCD pathophysiology.
- Clinical features
Diagnostic criteria: obsessions, compulsions, or both, that are time-consuming (typically more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important functioning.
- Differential diagnosis
Obsessive-compulsive personality disorder (OCPD): ego-syntonic (the patient does not see the perfectionism, preoccupation with order and rules, and rigidity as a problem), whereas OCD is ego-dystonic…
- Diagnosis
Diagnostic basis: the diagnosis is clinical, established by history of obsessions, compulsions, or both, that are time-consuming (typically more than 1 hour per day) or cause significant distress or…
- Management
First, screen for safety and comorbidity: assess for suicidal ideation and comorbid depression or substance use disorder before starting treatment, since these are common and change the treatment plan.
- Complications
Functional impairment: compulsions that consume more than 1 hour per day disrupt work, school, and relationships.
- Prognosis
Chronic course: OCD is often chronic and difficult to treat.
- Prevention
Relapse-prevention duration: continue effective pharmacotherapy for at least 1 to 2 years after response before considering a taper, since OCD is often chronic.
Read the whole article
Subscribing to Internal Medicine opens every article, the full question bank and MedBrain, on the web, iPhone and Android.
Related articles
- Generalized anxiety disorder
Generalized anxiety disorder is excessive, hard-to-control worry about multiple life domains occurring more days than not for at least 6 months, with at least 3 of 6 associated physical symptoms and functional impairment. Screen with the GAD-7 after excluding hyperthyroidism and substance use, then treat first-line with cognitive behavioral therapy and/or an SSRI or SNRI such as escitalopram or venlafaxine extended-release, reserving benzodiazepines for short-term severe symptom control only.
- Tourette syndrome
Tourette syndrome is a childhood-onset tic disorder defined by multiple motor tics plus at least 1 vocal tic present for more than 1 year, with onset before age 18 and near-constant psychiatric comorbidity such as obsessive-compulsive disorder and ADHD. Diagnosis is clinical; first-line management is psychoeducation and habit reversal training, escalating to an alpha-2 agonist or a VMAT2 inhibitor such as deutetrabenazine for disabling tics.
- Delusional disorder
Delusional disorder is a primary psychotic illness defined by one or more non-bizarre, fixed delusions lasting at least 1 month, without meeting criteria for schizophrenia and with functioning preserved outside the delusional theme. Diagnosis is clinical after a substance or medical cause is excluded. Management leads with psychotherapy, since antipsychotics are not effective for the core delusion, reserving a low-dose second-generation antipsychotic such as risperidone for overt psychosis or agitation.