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Obsession VS CompulsionObsession | Compulsion | Fear of contamination | Washing or cleaning rituals | Recurrent worries about doing things incorrectly/incompletely | Checking excessively, performing actions in a particular order | Need for symmetry | Ordering, arranging, straightening | Unwanted thoughts about being immoral | Asking forgiveness, praying, reassurance seeking | Concerns about throwing away something valuable | Hoarding |
Obsession is the fear, Compulsion is the response Goals of TreatmentShort-Term | Reduction in frequency and severity of obsessive thoughts; Reduction in time spent performing compulsive acts; improved psychosocial and occupational functioning; improved psychosocial and occupational functions | Long-Term | Remission |
Pharm | FIRST LINECitalopram | Escitalopram | Fluoxetine | ⇦ FDA APPROVED | Fluvoxamine | ⇦ FDA APPROVED | Paroxetine | ⇦ FDA APPROVED | Sertraline | ⇦ FDA APPROVED |
SSRI maximum doses in OCD are typically higher than max doses in anxiety and depression Duration of TherapyContinue Tx for at least 1 to 2 years | • 0 to 3 months: monitor Q wk to QOW | • 3 to 6 months: monitor Q month | • 6 to 24 months: monitor Q 1 to 2 months | Lifelong treatment recommended when: | • ≥ 2 severe relapses or ≥ 3 mild relapses | • Unable to achieve remission | Discontinuation or treatment | • Evaluate risks vs benefit | • taper slowly | • encourage non-pharmacologic tx |
| | DSM 5 Diagnostic CriterionPresence of obsessions, compulsions, or both | Must be time consuming (> 1 hour) OR Cause clinically significant distress in any area of life | Not attributed to a medical diagnosis or substance induced | Not better explained by another mental disorder |
Yale-Brown Obsessive-Compulsive Scale (Y-BOCS)Most commonly used scale | 40 point, 10-item clinician rated scale | Measures overall severity of obsessions and compulsions | Response: ≥ 25% reduction in score | Remission: score ≤ 8 |
Treatment ConsiderationsAppropriate when:
• an insufficient response to monotherapy (either drug or CBT)
• Patient prefers short duration
• Comorbid psychiatric conditions with no response to pharmacotherapy alone Pharm | SECOND LINECLOMIPRAMINE | TCA with strong 5-HT reuptake inhibition | Active metabolite inhibits NE reuptake | Studies showed it was more effective than SSRIs, but use is limited due to ADRs | True medication trial is at least 12 weeks at maintenance dosage |
Note: In PTSD, 8 to 12 weeks was a true medication trial |
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