Obsessive–compulsive disorder
Obsessive–compulsive disorder (OCD) is a mental disorder in which a person feels the need to perform certain routines repeatedly (called "compulsions"), or has certain thoughts repeatedly (called "obsessions").[1] The person is unable to control either the thoughts or activities for more than a short period of time.[1] Common compulsions include hand washing, counting of things, and checking to see if a door is locked. Some may have difficulty throwing things out. These activities occur to such a degree that the person's daily life is negatively affected,[1] often taking up more than an hour a day. Most adults realize that the behaviors do not make sense. The condition is associated with tics, anxiety disorder, and an increased risk of suicide.
The cause is unknown. There appear to be some genetic components with both identical twins more often affected than both non-identical twins. Risk factors include a history of child abuse or other stress-inducing event. Some cases have been documented to occur following infections.[2] The diagnosis is based on the symptoms and requires ruling out other drug related or medical causes. Rating scales such as the Yale–Brown Obsessive Compulsive Scale (Y-BOCS) can be used to assess the severity. Other disorders with similar symptoms include anxiety disorder, major depressive disorder, eating disorders, tic disorders, and obsessive–compulsive personality disorder.
Treatment involves counseling, such as cognitive behavioral therapy (CBT), and sometimes antidepressants such as selective serotonin reuptake inhibitors (SSRIs) or clomipramine. CBT for OCD involves increasing exposure to what causes the problems while not allowing the repetitive behavior to occur.[4] While clomipramine appears to work as well as SSRIs, it has greater side effects so is typically reserved as a second line treatment.[4] Atypical antipsychotics may be useful when used in addition to an SSRI in treatment-resistant cases but are also associated with an increased risk of side effects. Without treatment, the condition often lasts decades.
Obsessive–compulsive disorder affects about 2.3% of people at some point in their life.[6] Rates during a given year are about 1.2%, and it occurs worldwide.[2] It is unusual for symptoms to begin after the age of 35, and half of people develop problems before 20.[1][2] Males and females are affected about equally.[1] The phrase obsessive–compulsive is sometimes used in an informal manner unrelated to OCD to describe someone as being excessively meticulous, perfectionistic, absorbed, or otherwise fixated
The cause is unknown. There appear to be some genetic components with both identical twins more often affected than both non-identical twins. Risk factors include a history of child abuse or other stress-inducing event. Some cases have been documented to occur following infections.[2] The diagnosis is based on the symptoms and requires ruling out other drug related or medical causes. Rating scales such as the Yale–Brown Obsessive Compulsive Scale (Y-BOCS) can be used to assess the severity. Other disorders with similar symptoms include anxiety disorder, major depressive disorder, eating disorders, tic disorders, and obsessive–compulsive personality disorder.
Treatment involves counseling, such as cognitive behavioral therapy (CBT), and sometimes antidepressants such as selective serotonin reuptake inhibitors (SSRIs) or clomipramine. CBT for OCD involves increasing exposure to what causes the problems while not allowing the repetitive behavior to occur.[4] While clomipramine appears to work as well as SSRIs, it has greater side effects so is typically reserved as a second line treatment.[4] Atypical antipsychotics may be useful when used in addition to an SSRI in treatment-resistant cases but are also associated with an increased risk of side effects. Without treatment, the condition often lasts decades.
Obsessive–compulsive disorder affects about 2.3% of people at some point in their life.[6] Rates during a given year are about 1.2%, and it occurs worldwide.[2] It is unusual for symptoms to begin after the age of 35, and half of people develop problems before 20.[1][2] Males and females are affected about equally.[1] The phrase obsessive–compulsive is sometimes used in an informal manner unrelated to OCD to describe someone as being excessively meticulous, perfectionistic, absorbed, or otherwise fixated
Signs and symptomsOCD can present with a wide variety of symptoms. Certain groups of symptoms usually occur together. These groups are sometimes viewed as dimensions or clusters that may reflect an underlying process. The standard assessment tool for OCD, the Yale–Brown Obsessive Compulsive Scale (Y-BOCS), has 13 predefined categories of symptoms. These symptoms fit into three to five groupings.[10] A meta analytic review of symptom structures found a four factor structure (grouping) to be most reliable. The observed groups included a "symmetry factor", a "forbidden thoughts factor", a "cleaning factor", and a "hoarding factor". The "symmetry factor" correlated highly with obsessions related to ordering, counting, and symmetry, as well as repeating compulsions. The "forbidden thoughts factor" correlated highly with intrusive and distressing thoughts of a violent, religious, or sexual nature. The "cleaning factor" correlated highly with obsessions about contamination and compulsions related to cleaning. The "hoarding factor" only involved hoarding-related obsessions and compulsions, and was identified as being distinct from other symptom groupings.[11]
While OCD has been considered a homogeneous disorder from a neuropsychological perspective, many of the putative neuropsychological deficits may be due to comorbid disorders. Furthermore, some subtypes have been associated with improvement in performance on certain tasks such as pattern recognition (washing subtype) and spatial working memory (obsessive thought subtype). Subgroups have also been distinguished by neuroimaging findings and treatment response. Neuroimaging studies on this have been too few, and the subtypes examined have differed too much to draw any conclusions. On the other hand, subtype dependent treatment response has been studied, and the hoarding subtype has consistently responded least to treatment.
While OCD has been considered a homogeneous disorder from a neuropsychological perspective, many of the putative neuropsychological deficits may be due to comorbid disorders. Furthermore, some subtypes have been associated with improvement in performance on certain tasks such as pattern recognition (washing subtype) and spatial working memory (obsessive thought subtype). Subgroups have also been distinguished by neuroimaging findings and treatment response. Neuroimaging studies on this have been too few, and the subtypes examined have differed too much to draw any conclusions. On the other hand, subtype dependent treatment response has been studied, and the hoarding subtype has consistently responded least to treatment.
Obsessions are thoughts that recur and persist, despite efforts to ignore or confront them.[13] People with OCD frequently perform tasks, or compulsions, to seek relief from obsession-related anxiety. Within and among individuals, the initial obsessions, or intrusive thoughts, vary in their clarity and vividness. A relatively vague obsession could involve a general sense of disarray or tension accompanied by a belief that life cannot proceed as normal while the imbalance remains. A more intense obsession could be a preoccupation with the thought or image of someone close to them dying[14][15] or intrusions related to "relationship rightness".[16] Other obsessions concern the possibility that someone or something other than oneself—such as God, the devil, or disease—will harm either the person with OCD or the people or things that the person cares about. Other individuals with OCD may experience the sensation of invisible protrusions emanating from their bodies, or have the feeling that inanimate objects are ensouled.[17]
Compulsions
Some people with OCD experience sexual obsessions that may involve intrusive thoughts or images of "kissing, touching, fondling, oral sex, anal sex, intercourse, incest, and rape" with "strangers, acquaintances, parents, children, family members, friends, coworkers, animals, and religious figures", and can include "heterosexual or homosexual content" with persons of any age.[18] As with other intrusive, unpleasant thoughts or images, some disquieting sexual thoughts at times are normal, but people with OCD may attach extraordinary significance to the thoughts. For example, obsessive fears about sexual orientation can appear to the person with OCD, and even to those around them, as a crisis of sexual identity.[19][20] Furthermore, the doubt that accompanies OCD leads to uncertainty regarding whether one might act on the troubling thoughts, resulting in self-criticism or self-loathing.[18]
Most people with OCD understand that their notions do not correspond with reality; however, they feel that they must act as though their notions are correct. For example, an individual who engages in compulsive hoarding might be inclined to treat inorganic matter as if it had the sentience or rights of living organisms, while accepting that such behavior is irrational on a more intellectual level. There is a debate as to whether or not hoarding should be considered with other OCD symptoms.[21]
OCD sometimes manifests without overt compulsions, referred to as Primarily Obsessional OCD. OCD without overt compulsions could, by one estimate, characterize as many as 50 percent to 60 percent of OCD cases.
Compulsions
Some people with OCD experience sexual obsessions that may involve intrusive thoughts or images of "kissing, touching, fondling, oral sex, anal sex, intercourse, incest, and rape" with "strangers, acquaintances, parents, children, family members, friends, coworkers, animals, and religious figures", and can include "heterosexual or homosexual content" with persons of any age.[18] As with other intrusive, unpleasant thoughts or images, some disquieting sexual thoughts at times are normal, but people with OCD may attach extraordinary significance to the thoughts. For example, obsessive fears about sexual orientation can appear to the person with OCD, and even to those around them, as a crisis of sexual identity.[19][20] Furthermore, the doubt that accompanies OCD leads to uncertainty regarding whether one might act on the troubling thoughts, resulting in self-criticism or self-loathing.[18]
Most people with OCD understand that their notions do not correspond with reality; however, they feel that they must act as though their notions are correct. For example, an individual who engages in compulsive hoarding might be inclined to treat inorganic matter as if it had the sentience or rights of living organisms, while accepting that such behavior is irrational on a more intellectual level. There is a debate as to whether or not hoarding should be considered with other OCD symptoms.[21]
OCD sometimes manifests without overt compulsions, referred to as Primarily Obsessional OCD. OCD without overt compulsions could, by one estimate, characterize as many as 50 percent to 60 percent of OCD cases.
Insight
The DSM-V contains three specifiers for the level of insight in OCD. Good or fair insight is characterized by the acknowledgment that obsessive-compulsive beliefs are or may not be true. Poor insight is characterized by the belief that obsessive-compulsive beliefs are probably true. Absence of insight makes obsessive-compulsive beliefs delusional thoughts, and occurs in about 4% of people with OCD.
The DSM-V contains three specifiers for the level of insight in OCD. Good or fair insight is characterized by the acknowledgment that obsessive-compulsive beliefs are or may not be true. Poor insight is characterized by the belief that obsessive-compulsive beliefs are probably true. Absence of insight makes obsessive-compulsive beliefs delusional thoughts, and occurs in about 4% of people with OCD.
Overvalued ideas
Some people with OCD exhibit what is known as overvalued ideas. In such cases, the person with OCD will truly be uncertain whether the fears that cause them to perform their compulsions are irrational or not. After some discussion, it is possible to convince the individual that their fears may be unfounded. It may be more difficult to do ERP therapy on such people because they may be unwilling to cooperate, at least initially. There are severe cases in which the person has an unshakable belief in the context of OCD that is difficult to differentiate from psychotic disorders.
Some people with OCD exhibit what is known as overvalued ideas. In such cases, the person with OCD will truly be uncertain whether the fears that cause them to perform their compulsions are irrational or not. After some discussion, it is possible to convince the individual that their fears may be unfounded. It may be more difficult to do ERP therapy on such people because they may be unwilling to cooperate, at least initially. There are severe cases in which the person has an unshakable belief in the context of OCD that is difficult to differentiate from psychotic disorders.
Cognitive performance
Though it was once believed to be associated with above-average intelligence, this does not appear to be the case.[31] A 2013 review reported that people with OCD have mild but wide-ranging cognitive deficits; significantly regarding spatial memory, to a lesser extent with verbal memory, fluency, executive function, and processing speed, while auditory attention was not significantly affected.[32] People with OCD show impairment in formulating an organizational strategy for coding information, set-shifting, and motor and cognitive inhibition.[33]
Specific subtypes of symptom dimensions in OCD have been associated with specific cognitive deficits.[34] For example, the results of one meta-analysis comparing washing and checking symptoms reported that washers outperformed checkers on eight out of ten cognitive tests.[35] The symptom dimension of contamination and cleaning may be associated with higher scores on tests of inhibition and verbal memory.
Though it was once believed to be associated with above-average intelligence, this does not appear to be the case.[31] A 2013 review reported that people with OCD have mild but wide-ranging cognitive deficits; significantly regarding spatial memory, to a lesser extent with verbal memory, fluency, executive function, and processing speed, while auditory attention was not significantly affected.[32] People with OCD show impairment in formulating an organizational strategy for coding information, set-shifting, and motor and cognitive inhibition.[33]
Specific subtypes of symptom dimensions in OCD have been associated with specific cognitive deficits.[34] For example, the results of one meta-analysis comparing washing and checking symptoms reported that washers outperformed checkers on eight out of ten cognitive tests.[35] The symptom dimension of contamination and cleaning may be associated with higher scores on tests of inhibition and verbal memory.
Associated conditions
People with OCD may be diagnosed with other conditions, as well as or instead of OCD, such as the aforementioned obsessive–compulsive personality disorder, major depressive disorder, bipolar disorder,[39] generalized anxiety disorder, anorexia nervosa, social anxiety disorder, bulimia nervosa, Tourette syndrome, autism spectrum disorder, attention deficit hyperactivity disorder, dermatillomania (compulsive skin picking), body dysmorphic disorder and trichotillomania (hair pulling). More than 50 percent of people experience suicidal tendencies, and 15 percent have attempted suicide.[7] Depression, anxiety and prior suicide attempts increase the risk of future suicide attempts.[40]
Individuals with OCD have also been found to be affected by delayed sleep phase syndrome at a substantially higher rate than the general public.[41] Moreover, severe OCD symptoms are consistently associated with greater sleep disturbance. Reduced total sleep time and sleep efficiency have been observed in people with OCD, with delayed sleep onset and offset and an increased prevalence of delayed sleep phase disorder.[42]
Behaviorally, there is some research demonstrating a link between drug addiction and the disorder as well. For example, there is a higher risk of drug addiction among those with any anxiety disorder (possibly as a way of coping with the heightened levels of anxiety), but drug addiction among people with OCD may serve as a type of compulsive behavior and not just as a coping mechanism. Depression is also extremely prevalent among people with OCD. One explanation for the high depression rate among OCD populations was posited by Mineka, Watson and Clark (1998), who explained that people with OCD (or any other anxiety disorder) may feel depressed because of an "out of control" type of feeling.[43]
Someone exhibiting OCD signs does not necessarily have OCD. Behaviors that present as (or seem to be) obsessive or compulsive can also be found in a number of other conditions as well, including obsessive–compulsive personality disorder (OCPD), autism spectrum disorder, disorders where perseveration is a possible feature (ADHD, PTSD, bodily disorders or habit problems)[44] or sub-clinically.
Some with OCD present with features typically associated with Tourette's syndrome, such as compulsions that may appear to resemble motor tics; this has been termed "tic-related OCD" or "Tourettic OCD".[45][46]
OCD frequently co-occurs with both bipolar disorder and major depressive disorder. Between 60–80% of those with OCD experience a major depressive episode in their lifetime. Comorbidity rates have been reported at between 19–90% due to methodological differences. Between 9–35% of those with bipolar disorder also have OCD, compared to the 1–2% in the general population. Around 50% of those with OCD experience cyclothymic traits or hypomanic episodes. OCD is also associated with anxiety disorders. Lifetime comorbidity for OCD has been reported at 22% for specific phobia, 18% for social anxiety disorder, 12% for panic disorder, and 30% for generalized anxiety disorder. The comorbidity rate for OCD and ADHD has been reported as high as 51%
People with OCD may be diagnosed with other conditions, as well as or instead of OCD, such as the aforementioned obsessive–compulsive personality disorder, major depressive disorder, bipolar disorder,[39] generalized anxiety disorder, anorexia nervosa, social anxiety disorder, bulimia nervosa, Tourette syndrome, autism spectrum disorder, attention deficit hyperactivity disorder, dermatillomania (compulsive skin picking), body dysmorphic disorder and trichotillomania (hair pulling). More than 50 percent of people experience suicidal tendencies, and 15 percent have attempted suicide.[7] Depression, anxiety and prior suicide attempts increase the risk of future suicide attempts.[40]
Individuals with OCD have also been found to be affected by delayed sleep phase syndrome at a substantially higher rate than the general public.[41] Moreover, severe OCD symptoms are consistently associated with greater sleep disturbance. Reduced total sleep time and sleep efficiency have been observed in people with OCD, with delayed sleep onset and offset and an increased prevalence of delayed sleep phase disorder.[42]
Behaviorally, there is some research demonstrating a link between drug addiction and the disorder as well. For example, there is a higher risk of drug addiction among those with any anxiety disorder (possibly as a way of coping with the heightened levels of anxiety), but drug addiction among people with OCD may serve as a type of compulsive behavior and not just as a coping mechanism. Depression is also extremely prevalent among people with OCD. One explanation for the high depression rate among OCD populations was posited by Mineka, Watson and Clark (1998), who explained that people with OCD (or any other anxiety disorder) may feel depressed because of an "out of control" type of feeling.[43]
Someone exhibiting OCD signs does not necessarily have OCD. Behaviors that present as (or seem to be) obsessive or compulsive can also be found in a number of other conditions as well, including obsessive–compulsive personality disorder (OCPD), autism spectrum disorder, disorders where perseveration is a possible feature (ADHD, PTSD, bodily disorders or habit problems)[44] or sub-clinically.
Some with OCD present with features typically associated with Tourette's syndrome, such as compulsions that may appear to resemble motor tics; this has been termed "tic-related OCD" or "Tourettic OCD".[45][46]
OCD frequently co-occurs with both bipolar disorder and major depressive disorder. Between 60–80% of those with OCD experience a major depressive episode in their lifetime. Comorbidity rates have been reported at between 19–90% due to methodological differences. Between 9–35% of those with bipolar disorder also have OCD, compared to the 1–2% in the general population. Around 50% of those with OCD experience cyclothymic traits or hypomanic episodes. OCD is also associated with anxiety disorders. Lifetime comorbidity for OCD has been reported at 22% for specific phobia, 18% for social anxiety disorder, 12% for panic disorder, and 30% for generalized anxiety disorder. The comorbidity rate for OCD and ADHD has been reported as high as 51%
Diagnosis
Formal diagnosis may be performed by a psychologist, psychiatrist, clinical social worker, or other licensed mental health professional. To be diagnosed with OCD, a person must have obsessions, compulsions, or both, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM). The Quick Reference to the 2000 edition of the DSM states that several features characterize clinically significant obsessions and compulsions. Such obsessions, the DSM says, are recurrent and persistent thoughts, impulses or images that are experienced as intrusive and that cause marked anxiety or distress. These thoughts, impulses or images are of a degree or type that lies outside the normal range of worries about conventional problems.[82] A person may attempt to ignore or suppress such obsessions, or to neutralize them with some other thought or action, and will tend to recognize the obsessions as idiosyncratic or irrational.
Compulsions become clinically significant when a person feels driven to perform them in response to an obsession, or according to rules that must be applied rigidly, and when the person consequently feels or causes significant distress. Therefore, while many people who do not suffer from OCD may perform actions often associated with OCD (such as ordering items in a pantry by height), the distinction with clinically significant OCD lies in the fact that the person who suffers from OCD must perform these actions, otherwise they will experience significant psychological distress. These behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these activities are not logically or practically connected to the issue, or they are excessive. In addition, at some point during the course of the disorder, the individual must realize that their obsessions or compulsions are unreasonable or excessive.
Moreover, the obsessions or compulsions must be time-consuming (taking up more than one hour per day) or cause impairment in social, occupational or scholastic functioning.[82] It is helpful to quantify the severity of symptoms and impairment before and during treatment for OCD. In addition to the person's estimate of the time spent each day harboring obsessive-compulsive thoughts or behaviors, concrete tools can be used to gauge the person's condition. This may be done with rating scales, such as the Yale–Brown Obsessive Compulsive Scale (Y-BOCS). With measurements like these, psychiatric consultation can be more appropriately determined because it has been standardized
Formal diagnosis may be performed by a psychologist, psychiatrist, clinical social worker, or other licensed mental health professional. To be diagnosed with OCD, a person must have obsessions, compulsions, or both, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM). The Quick Reference to the 2000 edition of the DSM states that several features characterize clinically significant obsessions and compulsions. Such obsessions, the DSM says, are recurrent and persistent thoughts, impulses or images that are experienced as intrusive and that cause marked anxiety or distress. These thoughts, impulses or images are of a degree or type that lies outside the normal range of worries about conventional problems.[82] A person may attempt to ignore or suppress such obsessions, or to neutralize them with some other thought or action, and will tend to recognize the obsessions as idiosyncratic or irrational.
Compulsions become clinically significant when a person feels driven to perform them in response to an obsession, or according to rules that must be applied rigidly, and when the person consequently feels or causes significant distress. Therefore, while many people who do not suffer from OCD may perform actions often associated with OCD (such as ordering items in a pantry by height), the distinction with clinically significant OCD lies in the fact that the person who suffers from OCD must perform these actions, otherwise they will experience significant psychological distress. These behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these activities are not logically or practically connected to the issue, or they are excessive. In addition, at some point during the course of the disorder, the individual must realize that their obsessions or compulsions are unreasonable or excessive.
Moreover, the obsessions or compulsions must be time-consuming (taking up more than one hour per day) or cause impairment in social, occupational or scholastic functioning.[82] It is helpful to quantify the severity of symptoms and impairment before and during treatment for OCD. In addition to the person's estimate of the time spent each day harboring obsessive-compulsive thoughts or behaviors, concrete tools can be used to gauge the person's condition. This may be done with rating scales, such as the Yale–Brown Obsessive Compulsive Scale (Y-BOCS). With measurements like these, psychiatric consultation can be more appropriately determined because it has been standardized
Therapy
The specific technique used in CBT is called exposure and response prevention (ERP) which involves teaching the person to deliberately come into contact with the situations that trigger the obsessive thoughts and fears ("exposure"), without carrying out the usual compulsive acts associated with the obsession ("response prevention"), thus gradually learning to tolerate the discomfort and anxiety associated with not performing the ritualistic behavior. At first, for example, someone might touch something only very mildly "contaminated" (such as a tissue that has been touched by another tissue that has been touched by the end of a toothpick that has touched a book that came from a "contaminated" location, such as a school). That is the "exposure". The "ritual prevention" is not washing. Another example might be leaving the house and checking the lock only once (exposure) without going back and checking again (ritual prevention). The person fairly quickly habituates to the anxiety-producing situation and discovers that their anxiety level drops considerably; they can then progress to touching something more "contaminated" or not checking the lock at all—again, without performing the ritual behavior of washing or checking.[89]
ERP has a strong evidence base, and it is considered the most effective treatment for OCD.[89] However, this claim was doubted by some researchers in 2000, who criticized the quality of many studies.[90] A 2018 review found that an online metacognitive intervention improved symptoms in OCD.[91]
It has generally been accepted that psychotherapy in combination with psychiatric medication is more effective than either option alone
The specific technique used in CBT is called exposure and response prevention (ERP) which involves teaching the person to deliberately come into contact with the situations that trigger the obsessive thoughts and fears ("exposure"), without carrying out the usual compulsive acts associated with the obsession ("response prevention"), thus gradually learning to tolerate the discomfort and anxiety associated with not performing the ritualistic behavior. At first, for example, someone might touch something only very mildly "contaminated" (such as a tissue that has been touched by another tissue that has been touched by the end of a toothpick that has touched a book that came from a "contaminated" location, such as a school). That is the "exposure". The "ritual prevention" is not washing. Another example might be leaving the house and checking the lock only once (exposure) without going back and checking again (ritual prevention). The person fairly quickly habituates to the anxiety-producing situation and discovers that their anxiety level drops considerably; they can then progress to touching something more "contaminated" or not checking the lock at all—again, without performing the ritual behavior of washing or checking.[89]
ERP has a strong evidence base, and it is considered the most effective treatment for OCD.[89] However, this claim was doubted by some researchers in 2000, who criticized the quality of many studies.[90] A 2018 review found that an online metacognitive intervention improved symptoms in OCD.[91]
It has generally been accepted that psychotherapy in combination with psychiatric medication is more effective than either option alone
Medication
The medications most frequently used are the selective serotonin reuptake inhibitors (SSRIs).[4] Clomipramine, a medication belonging to the class of tricyclic antidepressants, appears to work as well as SSRIs but has a higher rate of side effects.[4]
SSRIs are a second line treatment of adult obsessive compulsive disorder (OCD) with mild functional impairment and as first line treatment for those with moderate or severe impairment. In children, SSRIs can be considered as a second line therapy in those with moderate-to-severe impairment, with close monitoring for psychiatric adverse effects.[87] SSRIs are efficacious in the treatment of OCD; people treated with SSRIs are about twice as likely to respond to treatment as those treated with placebo.[92][93] Efficacy has been demonstrated both in short-term (6–24 weeks) treatment trials and in discontinuation trials with durations of 28–52 weeks.[94][95][96]
In 2006, the National Institute of Clinical and Health Excellence (NICE) guidelines recommended antipsychotics for OCD that does not improve with SSRI treatment.[5] For OCD there is tentative evidence for risperidone and insufficient evidence for olanzapine. Quetiapine is no better than placebo with regard to primary outcomes, but small effects were found in terms of YBOCS score. The efficacy of quetiapine and olanzapine are limited by the insufficient number of studies.[97] A 2014 review article found two studies that indicated that aripiprazole was "effective in the short-term" and found that "[t]here was a small effect-size for risperidone or anti-psychotics in general in the short-term"; however, the study authors found "no evidence for the effectiveness of quetiapine or olanzapine in comparison to placebo."[5] While quetiapine may be useful when used in addition to an SSRI in treatment-resistant OCD, these drugs are often poorly tolerated, and have metabolic side effects that limit their use. None of the atypical antipsychotics appear to be useful when used alone.[8] Another review reported that no evidence supports the use of first generation antipsychotics in OCD.[98]
A guideline by the APA suggested that dextroamphetamine may be considered by itself after more well supported treatments have been tried
The medications most frequently used are the selective serotonin reuptake inhibitors (SSRIs).[4] Clomipramine, a medication belonging to the class of tricyclic antidepressants, appears to work as well as SSRIs but has a higher rate of side effects.[4]
SSRIs are a second line treatment of adult obsessive compulsive disorder (OCD) with mild functional impairment and as first line treatment for those with moderate or severe impairment. In children, SSRIs can be considered as a second line therapy in those with moderate-to-severe impairment, with close monitoring for psychiatric adverse effects.[87] SSRIs are efficacious in the treatment of OCD; people treated with SSRIs are about twice as likely to respond to treatment as those treated with placebo.[92][93] Efficacy has been demonstrated both in short-term (6–24 weeks) treatment trials and in discontinuation trials with durations of 28–52 weeks.[94][95][96]
In 2006, the National Institute of Clinical and Health Excellence (NICE) guidelines recommended antipsychotics for OCD that does not improve with SSRI treatment.[5] For OCD there is tentative evidence for risperidone and insufficient evidence for olanzapine. Quetiapine is no better than placebo with regard to primary outcomes, but small effects were found in terms of YBOCS score. The efficacy of quetiapine and olanzapine are limited by the insufficient number of studies.[97] A 2014 review article found two studies that indicated that aripiprazole was "effective in the short-term" and found that "[t]here was a small effect-size for risperidone or anti-psychotics in general in the short-term"; however, the study authors found "no evidence for the effectiveness of quetiapine or olanzapine in comparison to placebo."[5] While quetiapine may be useful when used in addition to an SSRI in treatment-resistant OCD, these drugs are often poorly tolerated, and have metabolic side effects that limit their use. None of the atypical antipsychotics appear to be useful when used alone.[8] Another review reported that no evidence supports the use of first generation antipsychotics in OCD.[98]
A guideline by the APA suggested that dextroamphetamine may be considered by itself after more well supported treatments have been tried
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