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Updated: Dec 27 2021

Obsessive-Compulsive Disorder

  • 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. 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%
        • prevalence increases by 1.5-2-fold during pregnancy
    • 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
  • 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
      • 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
  • Prognosis
    • Symptoms wax and wane, even with treatment
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