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Obsession VS Compulsion

Obse­ssion
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 Treatm­ent

Short-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 LINE

Citalopram
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 Therapy

Continue 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 Criterion

Presence 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
Useful in monitoring

Trea­tment Consid­era­tions

Pharma­cot­herapy ± CBT
Approp­riate 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 LINE

CLOM­IPR­AMINE
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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