Updated: 6/28/2020

Obsessive-Compulsive Disorder

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Snapshot
  • A 25-year-old woman presents to clinic for hair loss. She had been dealing with hair loss for a few months and reports an itching in her scalp. She is worried about an infestation of her hair and often picks at her scalp. She is preoccupied with these thoughts, which occur almost every hour, and has sought care at multiple doctors, dermatologists, and even exterminators. No infestation has been identified on her scalp. On exam, she has multiple patches of hair loss, with varying lengths of hair growing from each patch, and negative hair-pull test, suggestive of trichotillomania. She is referred to psychiatry for suspected obsessive-compulsive disorder.
Introduction
  • Overview  
    • obsessive-compulsive disorder is characterized by obsessive intrusive thoughts, sensations, or feelings that may be relieved by repetitive compulsive mental or physical actions
      • treatment is usually cognitive behavioral therapy or medications
  • Epidemiology
    • incidence
      • common, with a lifetime prevalence of 1.7-4%
    • demographics
      • males are more likely to have onset in adolescence and to have a comorbid tic disorder
    • risk factors
      • family history
  • Pathogenesis
    • mechanism
      • exact pathogenesis is unclear but research suggests that there are abnormalities in serotonin neurotransmission
      • twin studies also show a genetic influence, although a genetic mutation has not been identified
      • disorder is ego-dystonic
        • behavior inconsistent with one's own beliefs and attitudes
          • separates OCD from obsessive-compulsive personality disorder
  • Associated conditions
    • patients often have other psychiatric comorbidities, including mood and anxiety disorders
    • Tourette disorder
      • treat with risperidone
  • Prognosis
    • symptoms wax and wane, even with treatment
Presentation
  • Symptoms
    • obsessions and compulsions often occupy hours a day and interfere with daily life
    • recurrent and persistent intrusive thoughts (obsessions)
      • common obsessions include fear of contamination, need for symmetry, unwanted sexual thoughts, and doubts
      • causes anxiety and distress
    • repetitive behaviors (compulsions)
      • hand washing
      • putting items in order
      • checking and rechecking tasks
  • Physical exam
    • hand dermatitis
      • related to excessive hand washing
    • patchy hair loss
      • related to compulsive hair pulling or trichotillomania
    • excoriations or prurigo nodules
      • related to compulsive skin picking
Studies
  • Yale-Brown Obsessive Compulsive scale
    • to evaluate range and severity of symptoms
    • to monitor treatment response
Differential
  • Intrinsic atopic dermatitis
    • key distinguishing factors
      • treatment with topical steroids can help resolve rash
      • treatment with cognitive behavioral therapy and control of compulsions may not result in resolution of rash
  • Body dysmorphic disorder
    • key distinguishing factors
      • preoccupation with a perceived defect in one’s appearance, causing significant distress and dysfunction
      • treatment with cognitive behavioral therapy
Treatment
  • Lifestyle
    • cognitive behavioral therapy (CBT)
      • indications
        • all patients
        • some patients may not need pharmacologic treatment with successful behavioral therapy
  • Medical
    • serotonin selective reuptake inhibitors (SSRIs)
      • indications
        • first-line
        • often in addition to CBT
    • tricyclic antidepressant
      • indication
        • second-line
        • clomipramine
    • antipsychotics
      • indication
        • used as augmentation therapy
Complications
  • Continued psychologic distress and functional impairment

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Questions (7)
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(M2.PY.16.4682) A 35-year-old woman presents to clinic in emotional distress. She states she has been unhappy for the past couple of months and is having problems with her sleep and appetite. Additionally, she reports significant anxiety regarding thoughts of dirtiness around the house. She states that she cleans all of the doorknobs 5-10 times per day and that, despite her actions, the stress related to cleaning is becoming worse. What is this patient's diagnosis? Tested Concept

QID: 107299
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Obsessive compulsive disorder (OCD)

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Tic disorder

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Panic Disorder (PD)

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Generalized anxiety disorder (GAD)

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Obsessive compulsive personality disorder (OCPD)

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(M2.PY.16.100) An 11-year-old girl is brought into the clinic by her parents, who are distraught over her behavior. They state that over the past several months she has started to act oddly, combing the hair of her toy dolls for hours without stopping and repetitively counting her steps in the house. She is often brought to tears when confronted about these behaviors. The patient has no past medical history. When questioned about family history, the mother states she has needed close medical follow-up in the past, but declines to elaborate. The patient's vital signs are all within normal limits. On physical exam the patient is a well nourished 11-year-old girl in no acute distress. She has occasional motor tics, but the remainder of the exam is benign. What is the diagnosis in this patient? Tested Concept

QID: 105770
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Autism spectrum disorder (ASD)

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Generalized anxiety disorder (GAD)

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Obsessive compulsive disorder (OCD)

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Tourette's syndrome

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Major depressive disorder (MDD)

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(M3.PY.15.6) A 14-year-old girl presents to the pediatrician for behavior issues. The girl has been having difficulty in school as a result. Every time the girl enters her classroom, she feels the urge to touch every wall before heading to her seat. When asked why she does this, she responds, "I'm not really sure. I just can't stop thinking about it until I have touched each wall." The parents have noticed this behavior occasionally at home but were not concerned. The girl is otherwise healthy, has many friends, eats a balanced diet, does not smoke, and is not sexually active. Her temperature is 98.2°F (36.8°C), blood pressure is 117/74 mmHg, pulse is 80/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam is notable for a healthy young girl. Neurologic exam is unremarkable. There is no observed abnormalities in behavior while the girl is in the office. Which of the following is the most appropriate initial step in management for this patient? Tested Concept

QID: 102760
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Clomipramine

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Cognitive behavioral therapy

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Fluoxetine

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Lorazepam

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Risperidone

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(M2.PY.15.77) An 11-year-old boy is brought to the doctor by his father because his father is worried about the boy's performance in school and his lack of a social life. His father is also worried about the ongoing bullying his son is experiencing due to swearing outbursts the boy has exhibited for several years. During these outbursts, the boy contorts his face, blinks repeatedly, and grunts. His father is worried that the bullying will worsen and would like to see if there is a medication that can help his son. Which of the following medications is most likely to be beneficial? Tested Concept

QID: 106888
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Valproic acid

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Risperidone

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Lamotrigine

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Clonazepam

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Lithium

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Evidence (11)
EXPERT COMMENTS (10)
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