Obsessive-compulsive disorder (OCD)
DSM-5 diagnostic criteria
- Criterion A - Obsessions and/or compulsions : obsessions = recurring + persistent thoughts + images + impulses + experienced as intrusive and undesirable + generating anxiety or distress + the subject tries to suppress or neutralize them (compulsion) + compulsions = repetitive behaviors (washing + checking + ordering) or repetitive mental acts (praying + counting + repeating words) + in response to obsessions + according to rigid rules + aimed at reducing anxiety or preventing a feared event
- Criterion B - Time consumption : obsessions/compulsions take up more than an hour a day + or cause clinically significant distress + or impair social + occupational + school functioning
- Criterion C - Not attributable : symptoms are not due to the effects of a substance + or to another medical condition
- Criterion D - No better explanation : not best explained by another mental disorder (anxiety disorders + autism spectrum disorders + tics in Tourette's syndrome)
- Insight (disease awareness) : specify: good or satisfactory (subject recognizes that beliefs are irrational) + poor (unconvinced) + absent or delusional beliefs (convinced that fears are true) → poor or absent insight = poorer prognosis + more difficult response to treatment
Main obsessional themes and associated compulsions
| Obsessional theme | Typical obsessions | Associated compulsions |
|---|---|---|
| Contamination | Fear of being contaminated by germs + diseases + toxic substances + chemicals + body fluids | Excessive hand washing + prolonged showers + contact avoidance + compulsive surface disinfection |
| Symmetry and scheduling | Feeling that things are «out of place» + sensation of incompleteness + need for perfect symmetry | Ordering + aligning + arranging objects symmetrically + repeating actions until «right» is achieved» |
| Aggressive intrusions (ego-dystonic obsessions) | Intrusive thoughts of hurting loved ones + children + or self + impulses to use knives or push someone + fear of committing a violent act | Avoidance of knives and sharp objects + demand for reassurance + compulsive checking + mental rituals |
| Religious or moral obsessions (scrupulosity) | Fear of having committed a sin + of having blasphemed + of having said something immoral + recurring religious doubts | Excessive prayer + repeated confession + seeking reassurance + religious rituals |
| Sexual obsessions | Intrusive thoughts with sexual content deemed unacceptable (incest + unwanted homosexuality + paedophilia) + experienced as ego-dystonic (contrary to real desires) | Avoidance + mental rituals + demand for reassurance + rumination |
| Check | Doubtful that I locked the door + turned off the gas + unplugged an appliance + filled out a form correctly + caused an accident | Repeated checking of doors + appliances + forms + retrace your steps to make sure you haven't hurt anyone in the car |
| Hoarding | Fear of throwing away useful objects + fear of regret + feeling that objects have sentimental value | Accumulation of objects + inability to discard + invaded living space + (DSM-5 makes this a separate diagnosis: hoarding disorder) |
Treatment
- CBT - Exposure with response prevention (ERP) - first-line treatment : gradual, deliberate exposure to the situations + thoughts + or objects triggering the obsessions + without performing the compulsion (response prevention) → desensitization of the anxious response → habituation → reduction of the obsessional cycle + 60-80 % symptom reduction efficacy + reference treatment for all forms + individual + group + or intensive (3-4 week intensive exposure format)
- High-dose SSRIs (first-line pharmacological treatment) : SSRIs for OCD require higher doses than for depression and a longer onset of action (8-12 weeks before efficacy is assessed) + sertraline (Zoloft®) 100-200 mg/d + fluvoxamine (Luvox®) 200-300 mg/d (SSRI with the best documented OCD indication) + fluoxetine (Prozac®) 40-80 mg/d + paroxetine 40-60 mg/d + escitalopram 20-40 mg/d
- Clomipramine (Anafranil®) - tricyclic serotonergic antidepressant: comparable or superior efficacy to SSRIs in OCD + but greater adverse effects (anticholinergics + sedation + cardiac risk + risk of convulsions) → used if SSRIs insufficient + or in combination with a low-dose SSRI (50-75 mg/d) → effective dose 150-250 mg/d
- Combination SSRI + CBT : superior to each treatment alone in moderate to severe forms → recommended as first-line treatment if access to CBT available
- Pharmacological augmentation if partial response to SSRIs : addition of low-dose atypical antipsychotics (risperidone 0.5-2 mg/d + or aripiprazole 5-10 mg/d + or quetiapine 25-100 mg/d) → proven efficacy in refractory forms + particularly if comorbid tics (risperidone +++) + or if comorbid personality disorder
- IV ketamine (severe refractory forms) : NMDA antagonist → rapid reduction (hours) of obsessional symptoms → transient effect (1-2 weeks) → used as a bridge while waiting for SSRIs to take effect or before surgery
- Neuromodulation (severe refractory OCD) : Deep Brain Stimulation (DBS) of the nucleus accumbens + or the internal capsule → FDA-approved for refractory OCD (Humanitarian Device Exemption) → reserved for very severe + disabling + refractory forms to optimal pharmacological and psychological treatments
Consult a doctor or psychiatrist if recurrent intrusive thoughts + compulsive rituals + or repetitive behaviors take up more than an hour a day + disrupt work or relationships + or cause significant distress - these symptoms suggest OCD requiring psychiatric evaluation and initiation of CBT with ERP and/or SSRIs at an appropriate dose. Never confuse the intrusive ego-dystonic obsessions of OCD with a real intention to act - OCD patients suffer from their thoughts, not desire them. For initial assessment and referral to behavioral therapy, Clinique Omicron offers medical consultations at its points of service in Quebec and via telemedicine. To book an appointment, visit cliniqueomicron.ca.
Consult at Clinique Omicron
Clinique Omicron's specialized physicians and nurse practitioners (NPs) screen for OCD using validated tools (Y-BOCS + OCI-R scale), initiate pharmacological treatment with SSRIs at progressive and therapeutic doses (sertraline + fluvoxamine + fluoxetine), refer to therapists trained in CBT with ERP for moderate to severe forms, assess comorbidities (depression + Tourette's syndrome + bipolar disorder + ASD), and refer to psychiatry for refractory forms or those requiring pharmacological augmentation. Consultations are available at several points of service in Quebec, and via telemedicine. To book an appointment, visit cliniqueomicron.ca.
The content of this page is provided for information purposes only and does not replace the advice of a physician or psychiatrist. SSRIs in OCD require higher doses and a longer onset of action than in depression - do not conclude ineffectiveness before 8-12 weeks at therapeutic dose. Intrusive obsessions with aggressive or sexual content in OCD do not predict acting out - they are ego-dystonic and a source of suffering for the patient.
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